by Adam Kay
† CTG – or cardiotocograph – is a recording of baby’s heart rate and mum’s contractions that continually streams out of a printer like ticker tape in 1950s Wall Street.
Wednesday, 27 December 2006
A patient’s ten-year-old son has been sitting wordlessly for an hour in triage while his mum waits to be seen, staring at his laptop screen and tapping away. A Christmas present, I assume. It makes an irritating beeping sound every second or two. I should confiscate it and donate it to the nursing station – it looks twenty times newer and more advanced than any computer I’ve seen in the hospital, like comparing the Hubble telescope with a £1.99 pair of tartan-framed novelty glasses from a whisky distillery gift shop.
Beep. Beep. Beep. Still, at least it’s not a drum kit. His mum notices I’m staring and smiles, under the misapprehension that I think her son is in any way sweet.
‘He’s really into his codeine,’ she tells me. Jesus Christ. Hours of phone calls to child protection officers flash before my eyes, jackknifing across the rest of my shift. She looks at my clearly troubled face and repeats: ‘He’s really into his coding.’
Thursday, 28 December 2006
I struggle with the concept of addiction – I think a lot of people do if they aren’t addicts themselves. But it’s hard to apply a rational thought process to people who can’t be rational, whose minds have been taken hostage.
They’re hospital staples. The patient being slowly suffocated to death by his smoking-induced emphysema, shivering in his wheelchair in the hospital car park while he alternates puffs from his cigarette and his oxygen tank. The alcoholic who’s already lost his job and his family, warned by the doctors his liver is on the brink of cirrhotic no-return, but who still stops off at the pub for a post-discharge pint before he even makes it home.
And then there’s Patient KM, a lady in her sixties, about to kill herself with sharon fruits. I’ve been asked to review her by the surgeons for an episode of post-menopausal bleeding. I read a clinic letter in the notes before reviewing her, then have to re-read it, assuming the consultant’s secretary has been sniffing Tipp-Ex.
A decade or so ago KM underwent a gastrectomy* for stomach cancer and now has to keep to a strict diet, avoiding certain food types she can’t digest. Top of the list is the persimmon, or sharon fruit – not exactly a Granny Smith, so an easy fruit to avoid. You might think.
Growing up in Malta, Patient KM’s family tradition at Christmas has always involved eating sharon fruits, and this isn’t a tradition she is prepared to let slide, despite her surgeon’s threats.† She knew it wasn’t an idle threat either; these little fuckers have caused her to have five episodes of intestinal obstruction, ruining five separate Christmases – forming solid, concrete-like blockages in her colon and, on three separate occasions, requiring open surgery. The most recent was last week, when the surgeons sliced her open to squeeze the diospyrobezoar‡ out of her intestine, like a marble in a tube of toothpaste.
‘It just wouldn’t be Christmas without it,’ she tells me, and I’m not sure whether she’s talking about the fruit or her hospital admission for intestinal obstruction.
The next diary entry contains details of a medical procedure that may be extremely upsetting to read. If you wish to avoid this, please turn to here.
* An –ectomy means a surgical removal. So removal of the stomach is a gastrectomy, male sterilization is a vasectomy, and private medicine is a cashectomy.
† God knows why – I’ve since tried one, and they’re not much to write home about. Fibrous and flavourless, like a spherical raffia place mat. I don’t think Terry’s need to worry that Chocolate Orange sales are going to plummet in favour of sharon fruits any time soon.
‡ Would you believe there’s a medical term specifically and exclusively for a mass of undigested sharon fruit in an intestine? No wonder medical school takes so long, learning all this shit.
Friday, 29 December 2006
The concept of setting a Christmas ‘out of office’ doesn’t really apply in medicine. Babies don’t care about your plans to get acquainted with a large Baileys and the bottom of a tin of Celebrations – and medical emergencies don’t get any less frequent just because Slade is belting out of every shop’s PA system.
Prof Devereux’s surgical termination of pregnancy list is definitely too time-sensitive to take a week off. I’m rota’d into theatre with Prof today, and first on the list is Patient SH, whose unbelievably sad story is the stuff of ethics textbooks – she’s twenty-one and has a cardiac condition that means she’s unlikely to live if she continues with her pregnancy. At fifteen weeks into her pregnancy her heart function has already significantly deteriorated and she’s had to make the heartbreaking decision to end the pregnancy in order to save her own life.* So while the rest of the world was eating like a Tudor king, she was agonizing about the impossibly difficult decision she’d made, and today, while everyone sleeps off their four-day hangovers in front of Bourne movie reruns, she’s under general anaesthetic.
I’ve read her notes and know the story, but there’s no discussion about it at all in theatre. Prof Devereux is chatting to the anaesthetist, arguing about who got treated the worst by the Christmas Rota Fairy. Instead of sitting on the stool to do the procedure, Prof turns to me and asks, ‘Do you want to do it?’
I really, really don’t. It feels so selfish to even think this – who am I to worry about my feelings, standing next to a patient going through the darkest, most traumatic day of her life? But the procedure is going to be grim beyond words – one more trauma for me to push down into a box that’s already full to bursting.
D&Es are performed pretty rarely here; I’ve never even seen one before.† What will he think of me if I say no? Turning down a training opportunity is not a good look. Should I tell the truth, that I’d find it too upsetting? It would be easier to tell him I’m drunk, or that I failed medical school and have been using a forged hospital pass for the last three years. What kind of doctor can’t do their job because they’re too soft?
It dawns on me that the inappropriately cheery pub banter with the anaesthetist is Prof’s way of dealing with it. Doctors never debrief at home – if you don’t even talk about it with the people in the same room, perhaps it helps you avoid thinking about it at all. Singing carols while London is blitzed around you.
Or maybe Prof just has a harder, tougher shell than me, a genetic stoicism, and this is something he can cope with day in day out, that simply doesn’t pierce his armour.
If Patient SH is brave enough to go through this, then I should at least have the balls to step up for her. I say yes, even managing to sound keen. Prof clearly expects me to be grateful for the opportunity – it would be much quicker for him to do it himself rather than walk me through it. Besides, we’re saving a life here – without this procedure, the pregnancy will kill her – so who am I to think twice about doing that?
I wish I could say I was overreacting, that it was nowhere near as bad as I’d feared, but the truth is that every single step of it was absolutely horrible.
Dilating up the cervix with metal rods that feel almost barbaric in their size. Using an ultrasound to guide the instruments I put inside – a graphic, real-time reminder of what I’m doing. Grasping. Crushing. I see it all on the screen, but don’t feel it in my hands – I feel it in my soul. Ripping. Pulling. There are things they never tell you when you apply to this specialty – they couldn’t, you would run a mile. Praying it’s over. It isn’t. Pulling again. And again. Grateful for my surgical mask that hides my wobbling lip. Unable to reply to Prof Devereux’s breezy matter-of-fact instructions with anything other than a robotic ‘Mm-hm’ in case my voice cracks. Repeating again and again in my head that we’re saving a woman’s life here. Suction. Scrape. Done. Minutes that felt like weeks.
I’ve read in the past that, when a patient chooses a late surgical TOP over a medical TOP, some of the burden of distress shifts from patient to doctor. Suddenly I understan
d. And then I feel guilty for making this in any way about me. It’s nothing to do with me. I can go home, brood for a day or two, then allow it to fade into memory among the rest of the days I’d rather forget.
I’m jolted back into the here and now by Prof Devereux. ‘Right, we’re done! Wake her up!’ he bouncily announces to the anaesthetist. The jollity is almost reassuring. ‘Who’s the next customer?’
‘I need to head back to the ward, I’m afraid,’ I say. But I don’t. I need fresh air, or a quiet room. Even a noisy room – any room that isn’t this one.
‘No problem, you head off. I’ll write up the notes.’
I stand up from the stool. He puts his hand on my shoulder and squeezes hard – he knew. This is our secret – I’m in the club now. He turns back to the anaesthetist and exhales.
‘Are QPR playing today?’‡
* Pregnancy puts huge demands on the body, and every organ has to adapt, from the liver to the lungs. The heart works around 50 per cent harder than before pregnancy, pumping much more blood around the body, and it’s not something every single heart can cope with.
† Most surgical terminations of pregnancy (TOP) are performed before twelve weeks’ gestation, and are a much less complicated procedure, both technically and psychologically, using a small suction tube inserted into the neck of the womb. After thirteen weeks, surgical terminations of pregnancy would involve a D&E (dilatation and evacuation). This is a rare procedure, because terminations at such gestations are relatively uncommon, and the vast majority of them involve giving medication to induce a miscarriage. Some patients, however, opt for the surgical route, under general anaesthetic, so as not to go through the added emotional distress of an induced second-trimester miscarriage.
‡ I didn’t put this diary entry in my first book because I couldn’t face the thought of having to read it back again at the various proofing stages, and I felt very unsure about inflicting it on readers. I have since regretted this – it was one of the most impactful moments in my medical career.
Fourth Christmas
Who’s that you can see in his suit of magenta?
It’s me – I’ve been soaked head to toe in placenta
Wednesday, 19 December 2007
Another missive from the powers-that-be, thunking into my pigeonhole with the friendly vernacular of a death threat.
Today’s diktat – complete with crude Clip Art holly sprigs and so many semicolons per sentence it’s practically a cry for help – informs all staff that the colour of scrubs will change this month from blue to red. Just like the cups in Starbucks! How fun! Maybe they’ll also make us wear red velour hats with fluffy white trim instead of surgical caps, pointy-toed elfin winkle-pickers instead of theatre shoes, and replace the bleep’s normal screech with the piano intro from ‘All I Want for Christmas Is You’. I could totally get behind this.
But like a puppy in a gift box, this isn’t just for Christmas – it’s permanent. We’ll be like those profoundly damaged breakfast-TV perennials who take Wizzard at their word and celebrate Christmas 365 days a year. Word soon spreads that the reason for the change isn’t seasonal or sartorial – it’s financial, naturally.*
I like my scrubs blue or green; they’re a recognizable shorthand for ‘medical professional’ in a way that no other colour really is. At St Agatha’s they insisted on different-coloured outfits for every profession – orange for anaesthetists, grey for midwives, purple for obstetricians and so on. When the whole team bundled in for an emergency alarm, it was like someone had called the Power Rangers.
Why are red scrubs the answer to our hospital’s financial black hole? Is red a significantly cheaper dye? Are the department getting sponsorship from Virgin Atlantic? Nope. Blood doesn’t show up on red as easily, so they’re hoping patients won’t notice we’re drenched in the stuff.†
* Scrubs aren’t cheap – they need to cope with everything a hospital might fling at you, from all angles, often at great speed. They’re made of extremely high-quality cotton with a tightly knit high thread count, so the bugs can’t get in (or out, knowing some of my former colleagues). But more expensive for the hospital than buying the scrubs is getting them cleaned, pressed and de-Ebola’d for the next person. On labour ward you get through a particularly large number: it’s hard to emerge from any delivery unsplashed. You’re basically front row for Shamu at SeaWorld, except Shamu has eaten a dodgy kebab and is suffering from chronic fin rot. And call them picky, but the average patient prefers it if, when a doctor knocks on their door, they don’t look like they’ve just stepped out of a deleted scene from Saw.
† Hospitals are always looking for ways to cut the cost of laundering so many scrubs. At one place where I worked they piloted a vending machine set-up, which saw each changing room fitted with a scrubs dispenser that, upon waggling your SCRUBZCARD™ (or whatever it was) over the electronic reader, would dole out a fresh set of top and trousers. It sounded great in principle, but unlike a regular vending machine, which hurls your Crunchie into the dispensing tray at such speed and force it gets reduced to sand, this chilled-out dude ejected its product glacially – not the speed a labour ward tends to function at. It was like waiting for the Bible to finish coming out of an inkjet printer.
Every member of staff was given a SCRUBZCARD™, and an allocation of three outfits a day from the machine. Nightshifts were fine – the card regenerated its credits at 12 a.m., so there were three sets available before midnight and three sets after, which was enough for all but the very sloppiest shift. Day shifts were more of a trial, getting by on just three pairs, so we started to game the system, learning to stockpile them. On clinic days when we didn’t need to wear scrubs, we’d trot off to our robotic laundromat and relieve it of our full allocation, then hoard away our prized scrubs like those little glass pots from a chocolate dessert that might ‘come in handy’ one day.
Friday, 21 December 2007
On the one hand, my bleep has become a lot quieter since the new voice-activated switchboard system came in. On the other hand, it’s virtually impossible for me to contact anyone else.
Presumably because the hospital is in a thunderingly posh area, the software company imagined the staff were on nodding terms with the landed gentry, and the system has been programmed to only recognize absurdly snooty accents. Every ward is full of doctors and nurses repeatedly honking a word into phone handsets in progressively posher voices. ‘Theatre . . . thurta . . . thartaaaaah.’ It’s like an am-dram production of Gosford Park.
When you eventually manage to get switchboard’s satanic robot to understand a word you’ve said, it’s inevitably the wrong one. Today it would have been more efficient to get through to a radiologist with a couple of yoghurt pots and a length of string.
‘Radiology.’
‘Transferring you to Audiology. Or say: Cancel.’
‘CANCEL!’
‘Putting you through to Cancer Ward.’
Sunday, 23 December 2007
Like the gentle warm-down you do after a strenuous workout because it’s bad for your body to go straight from sixty to zero, my gruelling nightshift is immediately followed by a day shift acting down a grade, as an SHO. I’m doing a good deed – the SHO who was meant to be on duty tonight recently lost her grandfather and has been refused compassionate leave, which is apparently restricted to first-degree relatives only. How nice to be informed that your nearest and dearest have some corresponding value attached to them, like a game of genealogical Top Trumps. And as if being denied compassionate leave wasn’t enough, she couldn’t even take the day off as annual leave, as she had given ‘insufficient notice over the festive period’.
‘As you know, this is standard policy’ is HR’s default line – as if being routinely malevolent is somehow better than dishing out acts of spite on an ad-hoc basis. On the bright side, this is relatively kind for them. They’ve been known to demand death certificates as proof in the past, and even state that only the loss of a partner, rather th
an their urgent admission to intensive care, were sufficient grounds to knock off work for a couple of days.
Despite management’s unwavering insistence that she should miss her own grandad’s funeral, we’ve managed to come through for this SHO and cobble together a little arrangement among ourselves. I’m staying on an extra six hours, and tonight’s registrar is turning up six hours early. Ideally, she’d be able to grieve and support her family for more than a day, but it’s better than nothing. How utterly depressing that the top floor have their own inflexible commandments, yet the rules and regulations that are supposed to protect rank-and-file staff are always gamed or ignored when the need arises.
But it’s fine – relaxing almost! – working below my pay grade, even if it is for free. The registrar on the rota is a locum, naturally, and we both do our own thing for the most part. Out of courtesy, I let him know when I’ve admitted a patient, and we join forces twice to perform a couple of caesarean sections. I don’t mention to him that I’m normally a registrar so as not to undermine him.
My half of the shift is over and we’re about to say goodbye when he takes me aside and tells me I’m a good SHO.
‘You should consider acting up as a registrar,’ he says, shooting me the kind of patronizing grin I personally reserve for someone who tells me how clever their one-year-old is. ‘Maybe in six months or so,’ he adds.
Merry Christmas, you cunt.
Monday, 24 December 2007
