Twas the Nightshift Before Christmas

by Adam Kay

  † ENT is commonly known as Early Nights and Tennis – a good choice of specialty if you like a quiet Christmas. See also, dermaholiday.

  ‡ An AV (arteriovenous) malformation is a rare manufacturing fault where a spaghetti junction of arteries and veins forms. They most commonly occur in the brain, but can pop up anywhere. They have a tendency to bleed heavily, and this happens more frequently in pregnancy.

  Saturday, 31 December 2005

  ‘Say that again?’ asked Mitch.

  ‘She’s got extremely heavy thrush, with green and red flecks in it,’ I say.

  ‘So, blood then?’

  ‘No, it’s not blood, it’s . . . shiny. Like bits of toenail polish.’

  ‘Is it bits of toenail polish?’

  ‘I don’t think so . . .’

  I’m about to have another go at explaining but Mitch stops me, holding his finger aloft as if he’s about to conduct an orchestra, then walks off to review the patient. He glides back five minutes later, looking like he’s worked out the plot to Donnie Darko.

  ‘You didn’t ask the right questions,’ he says, every syllable a dunce’s cap thudding onto my head. ‘You see, 99 per cent of the time you’ll get the answer by taking a thorough history, before you even lay a hand on the patient.’

  I know I have to let his pompous little speech burn out before interrupting. Registrars like to do this kind of thing now and again to show they’ve ‘still got it’, like your uncle squeezing himself into his Speedos despite the gasps of terrified onlookers around the hotel pool. Once he’s done, I ask what the right question was.

  ‘Have you recently been using a candy cane as a dildo?’

  Of course! I’ll add that to my list of icebreakers.

  Sunday, 1 January 2006

  When the posters announced that the hospital was getting new discharge summary* software for 2006, like the world’s most boring New Year’s Resolution, I don’t think any of us imagined the big changeover would happen within the final echoes of Big Ben’s last bong on the first of January. To give the hospital an unusual amount of credit, they’ve laid on a bunch of IT ‘helpers’, wandering the corridors wearing bright sashes like regional semi-finalists in a Slimmer of the Year competition. The bloke assigned to the gynaecology ward agreed that the timing left a little to be desired. ‘At least we’re on triple pay!’ he trilled, hitting keys on a computer like a lab rat nudging the trapdoor for a treat. Triple pay? You may be but we certainly are not. I hope he spends the spoils on Aquafresh – his halitosis practically phones ahead to tell you it’s coming.

  I guess we should be grateful our technology is being coerced, if not into the twenty-first century, then certainly the mid-to-late twentieth. The old system was the stuff of Bob Cratchit’s nightmares: the doctor would write a summary of the patient’s stay on triplicate carbon paper. The top copy was for the notes, the middle one for the patient, and the bottom copy – with its faint suggestion of the original writing (unless you get a doctor prepared to channel all his anger into a biro) – posted off to the patient’s GP. But from today, all the information goes straight onto the computer system . . . before a copy is printed off and – give me strength – faxed to the GP.

  Technology may change, but the patients certainly don’t. On this morning’s ward round I meet Patient AW, who saw in the new year with a bang. Followed by a whimper.

  Finding herself in a suitor’s bedroom, in need of some vaginal lubrication, and having found no joy in either the bedside table or bathroom cabinet, she went to the kitchen for inspiration and returned with a tub of peanut butter. While she should definitely have carried on rooting through the cupboards, peanut butter wasn’t the most terrible choice – it’s an oil-based spread, plus it offers the option of smooth or crunchy, for your added ‘pleasure’. Downsides include the fact that oil-based lubricants are kryptonite to condoms, not to mention the potential for extreme mess: no cleaner is going to believe the brown slick on the sheet is peanut butter. Also, some people have peanut allergies. Patient AW, for example.

  ‘But . . . whyyyy?’ I asked, stretching the word longer than Annie Lennox ever managed.

  ‘I assumed it was only a problem, you know, up the other end,’ she explained. I imagine she was too caught up in the moment to google it, but her theory proved incorrect. Luckily, she escaped the worst-case scenario of breathing difficulties and ultimately, well, not breathing at all, but she did develop vaginal and vulval swelling to the extent she couldn’t pass urine. My colleagues on the nightshift had catheterized her, washed everything out (making them the automatic winners of any ‘who had the worst New Year’s Eve?’ conversation) and started her on steroids and antihistamines.

  This morning the disaster zone has calmed down, the catheter has been removed and she’s peeing successfully without it, so I discharge her home. We’re in mutual agreement she shouldn’t engage in future use of intravaginal Sun-Pat.

  And so to try out the new computer system. The IT helper – cheese, onion, and sewage sandwich for lunch, it appears – is talking me through the software. Apparently I need to choose the diagnosis from a telephone directory of pre-programmed, ultra-specific options.

  ‘How would you describe the patient’s diagnosis in one or two words?’ he asks.

  I pause. ‘Vaginaphylaxis?’

  * For once, a term that’s less revolting than you might fear. A discharge summary is the paperwork that gives the patient and their GP a potted history of their hospital stay, the medication they’re going home with, and any planned follow-up.

  Wednesday, 4 January 2006

  After a couple of months of waiting on the edge of my seat, the final adjudication is through on the locum nightshift I did in October, when the clocks went back and I put in a timesheet for thirteen hours.

  ‘Shifts are defined as twelve hours,’ the email barks, ‘irrespective of the number of hours worked.’ Who needs the scientific laws of space and time when you’ve got whichever handbook this bastard flicked through to get the answer? I’m pretty sure that if I’d worked the night the clocks went forward, I’d only get paid for eleven.

  Thursday, 5 January 2006

  ‘I don’t want to die,’ Patient JM said, plaintively. None of us want to die, of course – it’s human nature – but I was surprised to hear it from the mouth of a ninety-one-year-old. We’re conditioned to describe this as a good innings, but when you’re lying in a hospital bed with all signs pointing towards your permanent exit from the planet, age doesn’t really come into it. If anything, those extra couple of decades thinking about the final page of the story probably make it all the more difficult to approach.

  I decided the best thing to do was pretend I hadn’t heard what she’d said, and continued to insert the drip in her hand, as if I was concentrating so hard it had rendered me deaf. She waited until the drip was in, then touched my hand, her skin so loose it didn’t feel quite human. ‘Is this it?’ she asked, her eyes searching mine as I stared back vacantly. ‘Am I dying?’

  She knew. I’d given her tacit confirmation by not answering the first time. And she was dying – it wouldn’t be more than a day away. The more patients I see, the more I can tell – it’s not just the black-and-white of measurable things like respiratory rates and full blood counts, or even the clinical signs like laboured breathing and mottled skin. It’s an aura, if doctors are allowed to use such a word, and working in gynae oncology has made me far more attuned to it.

  I’d never been asked this before, and I had no idea how to deal with it. Every day brings new challenges I don’t have the cheat sheet for, like a recurring nightmare where you turn up for your finals drunk and unprepared.

  After too long a pause, I copped out and lied: ‘No, don’t be silly!’ Not just ‘No’ but ‘No, don’t be silly!’ – negating her, throwing her off the scent, in reply to the bravest question of all. She looked back at me without a hint of relief and pretended to accept my answer with a faint smile, then slowly leaned her head
back to look up at the ceiling, as if imagining herself among the stars. Once eye contact was broken, I made my excuses and scuttled off.*

  I realize I never actually talk about death with patients – their families, my colleagues, sure, but not them. For the rest of the nightshift, I obsess over what I should have said. All she wanted was someone to be straight with her and confirm what she knew deep down. At ninety-one she’s earned that right. Instead, I was too scared to tell the truth, and I let her down.

  When that day arrives for me, if I’m able to ask my doctor that question, I want them to be honest – and then I want them to hook me up to the largest bottle of vodka they can carry.

  At the end of the shift, I trudge back to her ward. I tell myself I’m going to speak to her again, giving myself a motivational pep talk as I go. You’ve got this, I say, you owe it to her. But, shamefully, I’m half hoping that I won’t have to.

  There’s an empty bed in bay three. I don’t have to.

  * The eminent palliative care doctor Kathryn Mannix writes beautifully and powerfully about this topic in her book, With the End in Mind. Not just healthcare professionals, but all of us need to be honest and unafraid to talk about death.

  Third Christmas

  Come Dancer! Come Prancer! Come Rudolph! Come Comet!

  Come rescue me now cos I’m covered in vomit

  Monday, 20 November 2006

  The Christmas rota has been emailed round and – jingle balls – I’ve drawn the short straw.

  Colleagues give me sympathetic looks all day. Donald, one of the other SHOs, pats me on the back. ‘Hard lines, mate.’ I open my mouth to tell him it’s fine, when he jumps straight in with, ‘My mum’s dying and it’s the last Christmas I’m going to spend with her.’

  ‘Oh god, Don – I’m so sorry, I had no idea. I wasn’t asking to swap . . .’

  ‘No no, it’s my suggestion for you – email them back with that as your excuse.’

  Tuesday, 19 December 2006

  We’re invited to donate a fiver to charity and wear Christmassy clothes today. Most people have gone for jaunty jumpers, so the air crackles with acrylic charge, staff becoming human Van de Graaff generators if they get within a foot of each other. I’ve cracked out my musical Rudolph tie, representing as it does the sole contents of my Christmas wardrobe.

  We set off on the gynae ward round. I clasp my hands together a few inches away from my chest to stop anyone or anything bashing into my tie and setting off a chorus or twelve of ‘Jingle Bells’. Even though I look like some mad medical Buddha, it’s not me who attracts attention.

  ‘I’m very sorry to ask this,’ Marv, one of the registrars, says to Miss Balzak. ‘Those reindeer on your jumper – do you think they might be . . . having a bit of “ladies and gentlemen”?’

  Miss Balzak looks down at her sweater: racing green with white cross-stitched rows of snowflakes top and bottom and three reindeer in between. The middle reindeer is subtly, but quite unmistakably, mounting the reindeer on the right and being rimmed by the smaller reindeer on the left. Not the usual look you’d expect on someone who makes Miss Marple look like Sharon Stone.

  ‘Oh, for goodness’ sake,’ says Miss Balzak. ‘They bloody are, aren’t they?’ She’d picked it up from a stall in Camden Market when she was out Christmas shopping because she thought it looked fun, not quite noticing just how much fun Rudolph’s red nose was having.

  ‘Shall we wait while you change?’ asks Marv.

  Miss Balzak ignores him. ‘Who’s next? Bay eight?’

  Friday, 22 December 2006

  Patient FJ is pushing, I’m on forceps duty, and the radio is shitting out the Christmas classics. I’ve done my second pull (accompanied by Johnny Mathis), the baby is nearly out, and we’re all catching our breaths before the grand finale.

  The patient suddenly shouts at the radio.

  ‘No, Johnny. That is not what happens when a child is born.’

  Saturday, 23 December 2006

  As crap as it is working in hospital over Christmas, it’s easy to forget how much worse it must be for the patients, so it’s all hands on deck over the next couple of days to get anyone home who’s vaguely well enough to wheel or drag themselves off the ward. Patients are Lazarus-ed out of their beds and switched from festive-sounding IV antibiotics to the more portable oral variety, to get them back to the bosom of their loving families. The added bonus being that, with the indentation from the hospital wristband still on their arm, they’ll be excused so much as pouring themselves an Advocaat, let alone carving the turkey, mopping the floor or consoling a child who wanted an Xbox but got an atlas.

  Patient BC is seventy-two and well enough post-op to go home. I’ve quite enjoyed springing from bedside to bedside breaking good news, like a game-show host telling a contestant they’ve won a Mini Metro or a luxury holiday for four to Torremolinos. But when I get to Patient BC, her face doesn’t light up like the others – she just mutters ‘OK’ and looks away.

  I hover.

  ‘Hmm. Your wound is looking a bit red, though,’ I offer. It isn’t. She looks back round at me. ‘Maybe we should keep an eye on it over the next few days?’

  Her entire body relaxes. It’s the kind of reaction you only usually see when you tell a patient their biopsy result is normal. I daren’t ask what kind of desperate domestic set-up, or lack thereof, means she’d rather be here than at home, but at least we can offer her a roof, a bit of company and some NHS parsnips. It’s a new twist on the classic ‘granny dump’, but I suspect this is actually the biggest help I’ve been to a patient all day.

  Sunday, 24 December 2006

  ‘Spot diagnosis?’ asks one of the paediatric SHOs, showing a photo on his phone around the doctors’ mess. It’s a child aged about four with a green face. Not ‘a bit peaky’ green, but ‘uranium in the sandpit’ luminescent. Maybe his dad’s the Incredible Hulk and he’s having his first tantrum?

  Answer: he’d dismantled his mum’s novelty earrings and shoved an LED up his nose, not realizing how much better a red light would have been for a Christmas anecdote.

  Monday, 25 December 2006

  Despite all my best efforts, it’s a hat-trick: three Christmases on the trot opening up patients instead of presents. Tentative efforts to swap with colleagues were batted away like bluebottles. Not sure what I expected them to say. ‘Bollocks to my husband, angelic children, and plans that have been set in stone for months – sure, I’ll spend the day knee-deep in amniotic fluid instead.’

  H took the news pretty well, all things considered, but I’m still half-expecting to find every pair of shoes I own filled with cranberry sauce when I get home.

  Cheerier relationship news with the discovery that Molly, one of the midwives, is dating Petr, an A&E nurse. It’s like when you hear that a pair of celebrities have coupled up and you try to imagine them together – cooking pasta, doing the big shop, arguing, fucking, reverse parking, watching Corrie – before giving them the Gladiator-style thumbs-up or thumbs-down.

  It’s been going on for months apparently, but they’ve never broadcast the fact. We only found out because they’re both working today and Petr has rocked up on labour ward to surprise Molly with a full Christmas dinner for two: lovingly prepared last night, transported in Tupperware and now spinning round in the labour ward microwave. He even colluded with Sondra, the midwife supervisor, who has given Molly a break and cleared the rest of us out of the coffee room so they can have some time together. Sondra has even laid on a tablecloth (well, blue drape) for that extra touch of class.

  The rest of us walk up and down the corridor a few times more than might be strictly necessary so we can steal a peek through the coffee room door. On the face of it, this is not a Christmas dinner that will be troubling the Michelin guide any time soon – nuked roast potatoes, desiccated turkey and coagulated gravy wolfed down in a thirty-minute lunch break in a room that should probably be condemned. But it’s the thought behind it – the rom-com sweetness –
that elevates it to the most beautiful thing I have seen all week, and makes me physically jealous of a Christmas spent together.

  I’m bleeped away to see Patient NW, who has come to labour ward with reduced fetal movements at thirty-eight weeks.* The CTG † is a bit manky and the baby’s breech – so caesarean section it is. ‘Oh, for fuck’s sake,’ she says.

  I reassure her everything’s going to be absolutely fine for her and baby. ‘Oh, it’s not that,’ she groans. ‘My other one was born on Christmas Day too. Everyone’s going to think I do this deliberately to save on presents.’

  I leave the room and see Petr and Molly snatching a kiss before they shoot off for another seven hours of the great British public’s contusions and contractions. Thumbs-up from me. Not sure I want to imagine them fucking, though.

  * Mums know when there’s something wrong with their unborn children. They’re connected by more than just an umbilical cord, it’s an almost psychic bond, and it’s a negligent obstetrician who disregards a mother’s hunch. This is, of course, in stark contrast to almost every other branch of medicine, where the mad shit that’s resulted from a patient’s frantic googling carries a roughly zero per cent chance of tallying up with their actual diagnosis.

  Sometimes reduced fetal movements are a sign of something being wrong, but often a baby has simply decided that they’re ‘doing downtime’ – an exciting glimpse into their future teenage aesthetic – and soon comes round when mum drinks a glass of cold water. It’s the maternofetal version of chucking a bucket of water over their head. Again, worth remembering for their teenage years.