by Henry Marsh
6
ANGOR ANIMI
n. the sense of being in the act of dying, differing from the fear of death or the desire for death.
Just as I had first gone to Ukraine out of curiosity and not from any particular wish to help Ukrainians – although I have now been working there for more than twenty years – I had become a doctor not from any deep sense of vocation but because of a crisis in my life.
Until the age of twenty-one I had followed the path that seemed clearly laid out for me by my family and education. It was a time when people from my background could simply assume that a job was waiting for them – the only question was to decide what you wanted to do. I had received a private and privileged English education in a famous school, with many years devoted to Latin and Greek, and then to English and History. I took two years off on leaving school, and after several months editing medieval customs documents in the Public Record Office (a job organized by my father through his many connections), spent a year as a volunteer teaching English literature in a remote corner of West Africa. I then went up to Oxford to read Politics, Philosophy and Economics.
I was destined, I suppose, for an academic or administrative career of some kind. During all these years I had received virtually no scientific education. Apart from a maternal great-grandfather who had been a village doctor in rural Prussia in the early decades of the last century there was nothing medical or scientific in my family background. My father was an eminent English human rights lawyer and academic, and my mother a German refugee from Nazi Germany who would probably have been a philologist if she hadn’t refused to join the women’s branch of the Hitler Youth – the League of German Maidens – and hence had been denied entry into university. Apart from the one doctor in Prussia my ancestors on both sides of my family were teachers and clergymen and tradesmen (although my uncle had been a Messerschmitt fighter pilot in a crack squadron until shot down in 1940).
While at Oxford, I fell in love, love which was unrequited, and driven by self-pitying despair I had, to my father’s deep dismay, abandoned university and run away to work as a hospital porter in a mining town in the north of England, trying to emulate Jack Nicholson heading off for Alaska at the end of the movie Five Easy Pieces. I spent six months there, spending the days lifting patients on and off operating tables, cleaning walls and equipment and assisting the anaesthetists.
I lived in a small room in a semi-derelict old fever hospital with a corrugated iron roof on the muddy banks of the polluted River Wansbeck. It was a few miles away from the coast where the beaches were black with sea-coal. There was a huge coal-fired power-station which I could see in the distance from my room, with high chimneys pouring white smoke and steam into the wind off the sea. At night the rising steam was lit by the arc-lamps that stood over the mountains of coal beside the turbine halls, over which I could see bulldozers crawling beneath the stars. I wrote second-rate, self-obsessed poetry in which I described this view as being of both heaven and hell. Full of youthful melodrama I saw myself as living in a world as red as blood and as white as snow – although the surgery I saw was not especially bloody and the winter was mild, without any snow.
I was profoundly lonely. In retrospect I was obviously trying to realize my own unhappiness by working in a hospital, in a place of illness and suffering, and perhaps I was curing myself of my adolescent angst and unrequited love in the process. It was also a ritual rebellion against my poor, well-meaning father who up till then had largely determined the course of my life. After six months of this I desperately wanted to come home – both to my family but also to a professional middle-class career, although one of my own choosing. Having spent six months watching surgeons operating I decided that this was what I should do. I found its controlled and altruistic violence deeply appealing. It seemed to involve excitement and job security, a combination of manual and mental skills, and power and social status as well. Nevertheless, it was not until eight years later when as a junior doctor I saw that first aneurysm operation that I discovered my vocation.
I was fortunate that my college at Oxford allowed me to come back after my year away to complete my degree and I was later accepted to study medicine at the only medical school in London which took students without any scientific qualifications. Having been rejected by all the other London Medical Schools since I had neither O-levels nor A-levels in science I had telephoned the Royal Free Medical School. They asked me to come for an interview next day.
The interview was with an elderly, pipe-smoking Scot, the Medical School Registrar, in a small and cramped office. He was to retire a few weeks later and perhaps he let me in to the Medical School as a kind of joke, or celebration, or perhaps his mind was elsewhere. He asked me if I enjoyed fly-fishing. I replied that I did not. He said that it was best to see medicine as a form of craft, neither art nor science – an opinion with which I came to agree in later years. The interview took five minutes and he offered me a place in the Medical School starting three weeks later.
Selection for medical schools has become a rather more rigorous process since then. I believe the Medical School at the huge London hospital where I now work uses role-playing with actors, along with many other procedures, to select the doctors of the future. The nervous candidates must show their ability to break bad news by telling an actor that their cat has just been run over by a car. Failure to take the scenario seriously, I am told, results in immediate rejection. Whether this is any better than the process I went through remains, I believe, unproven. Apparently the actors help select the successful candidates.
I joined what was called a First MB course – which was a year’s crash course in basic science, and which led on to the Second MB course, which was the standard five-year course of undergraduate medical training. This was the last year that the medical school ran a First MB Course and the department was something of a scientific and academic backwater, with the course taught by a number of eccentric and often embittered scientists – although many of them were at the very beginning of their careers, and rapidly moved on elsewhere. One became a famous science writer, another eventually became a peer and Chairman of the Tory party. The others were older teachers approaching retirement, some of whom did not bother to hide their dislike of the slightly odd mix of First MB students – a stockbroker, a Saudi princess, a Ford truck salesman – mixed up with other, younger students who had poor A-level results (and one, it turned out, who had forged them). Our days were spent gradually dissecting and dis-assembling large white rabbits for biology, titrating chemicals for chemistry and failing to understand the physics lectures. Some of the lecturers were inspiring, some risible. The atmosphere was anxious, verging on hysterical – we were all desperate to become doctors and most of us felt a failure for some reason or other, although as far as I can remember we all passed the final examination.
I then spent two years of pre-clinical studies in the medical school – anatomy, physiology, biochemistry and pharmacology – followed by three years as a clinical student in the hospital. The anatomy involved the students being divided up into small groups and each group was given an embalmed cadaver which we slowly took apart over the course of the year. Not especially attractive to begin with, the cadavers were a sorry sight by the year’s end. The bodies were kept in the Long Room – a large and high attic space with skylights, with half a dozen trolleys on either side with sinister shapes covered by green tarpaulins. The place smelled strongly of formaldehyde.
On the first day of the course, holding our newly purchased dissection manuals with a few instruments in a small canvas roll, we queued up a little nervously on the stairs leading to the Long Room. The doors were opened with a flourish by the Long Room attendant and we went in to be presented to our respective, intact corpses. It was a traditional part of medical education going back hundreds of years but has now been largely abandoned. As a surgeon one has to learn real anatomy all over again – the anatomy of a living
, bleeding body is quite different from the greasy, grey flesh of cadavers embalmed for dissection. The anatomy we learnt from dissection was perhaps of limited value, but it was an important initiation rite, marking our transition from the lay world to the world of disease and death and perhaps inuring us to it. It was also quite a sociable process as one sat with a group of fellow students around one’s cadaver, picking and scratching away at dead tissue, learning the hundreds of names that had to be learnt – of the veins and arteries and bones and organ parts and their relations. I remember being particularly fascinated by the anatomy of the hand. There was a plastic bag of severed hands in the anatomy department in various stages of dissection from which I liked to make elaborate, coloured drawings, in imitation of Vesalius.
In 1979 I emerged onto the wards of the hospital where I had trained wearing the long white coat of a junior doctor as opposed to the short white coat of a medical student. I felt very important. Other hospitals, I later noticed to my confusion, had the medical students in long white coats and the junior doctors in short ones. Like a badge of office I proudly carried a pager – known colloquially as a bleep – in the breast pocket with a stethoscope, a tourniquet for blood-taking and a drug formulary in the side pockets. Once you had qualified from medical school you spent a year as a junior house officer – a sort of general dogsbody – with six months working in surgery and six months in medicine. If you wanted a career in hospital medicine as a surgeon or physician – as opposed to becoming a GP – you tried to get a housejob in the teaching hospital where you had trained as a student, so as to make yourself known to the senior doctors, on whose patronage your career entirely depended.
I wanted to be a surgeon – at least I thought I did – so I managed to get a job on a surgical ‘firm’, as it was called, in my teaching hospital. The firm consisted of a consultant, a senior registrar and a junior registrar and the houseman. I worked ‘1 in 2’, which meant I did a normal working day five days a week, but also was on call every other night and every other weekend, so I was in the hospital for about 120 hours a week. My predecessor had handed me over the bleep with a few words of advice about how to keep the boss happy and how to help patients who were dying – neither subject being dealt with in the lectures and textbooks. I enjoyed the feeling of power and importance the long hours gave me. In reality, I had little responsibility. The days and nights were spent clerking in patients, taking blood, filling up forms and chasing up missing X-rays. I usually got just enough sleep, and I became used to being disturbed at night. Occasionally I assisted in theatre, which meant long hours standing still, holding patients’ abdomens open with retractors while my seniors rummaged about. Looking back now, thirty years later, my sense of my own importance at that time seems quite laughable.
Much as I liked being part of the small army of junior doctors in the hospital, as the months as a surgical houseman passed I became increasingly uncertain as to what I was going to do with my medical career. The reality of surgery had proved quite different from my superficial impressions of it when a theatre porter. Surgery seemed to involve unpleasant, smelly body parts, sphincters and bodily fluids that I found almost as unattractive as some of the surgeons dealing with them, although there were a few surgical teachers in the hospital without whose influence I would never have become a surgeon. It was their kindness to patients, as much as their technical skill, which I found inspiring. I saw no neurosurgery as a medical student or houseman. The neurosurgical operating theatre was out of bounds, and people spoke of it with awe, almost alarm.
My next six months as a houseman were in a dilapidated old hospital in south London. The building had housed a workhouse in the nineteenth century and it was said it had not yet escaped its dismal previous reputation with the local population. It was the sort of hospital which made the British public’s devotion to the NHS quite incomprehensible, with the patients housed like cattle in the old workhouse rooms – large and ugly rooms with dozens of beds lined up on either side. The Casualty department was on the ground floor and the Intensive Care Unit on the first floor immediately above it, but there was only one lift in the hospital which was one quarter of a mile away down the main hospital corridor. If a patient had to be transferred urgently from Casualty to the ITU it was the task of the junior houseman on call, with the help of a porter, to push the patient’s bed all the way down the corridor from one end of the hospital to the other, take the lift, and then push the patient and bed all the way back again. I tried to do this as quickly as possible, pushing people in the corridor out of the way and commandeering the large and rattling old lift, creating a sense of drama and urgency. I doubt if it was clinically necessary but it was how it was done on TV and was good fun. Even though I got little sleep at night there was a doctors’ mess and bar run by a friendly Spanish lady who would cook me a meal at any time of night. There was even a lawn outside the main building where I would play croquet with my fellow junior doctors when we had the time.
It was busy work with more responsibility than my first job as a house surgeon, and with much less supervision. I learnt a lot of practical medicine very quickly but they were not always enjoyable lessons. I was at the bottom of a little hierarchy in the ‘firm’. My job was to see all the patients – most of whom were admitted as emergencies through the Casualty department – when they arrived and to look after the ones already on the wards. I learnt very quickly that I did not ring up my seniors about a patient without having first seen the patient myself. I had done this on my first night on call, asking my registrar’s advice in advance of going to see a patient the nurses had called me about, and received a torrent of abuse in reply. So, anxious and inexperienced, I would see all the patients, try to decide what to do, and only dare to ring my seniors up if I was really very uncertain indeed.
One night, shortly after I had started, I was called in the early hours to see a middle-aged man on the ward who had become breathless, a common enough problem on a busy emergency medical ward. I got out of bed and pulled on my white coat (I slept with my clothes on since one rarely got more than an hour or two of sleep without being called to Casualty or the wards). I walked onto the long and darkened Nightingale ward with its twenty beds on either side facing each other. Restless, snoring, shifting shapes lay in them. Two nurses sat at a desk in the middle of the room, a little pool of light in the darkness, doing paperwork. They pointed to the patient they wanted me to see.
‘He came in yesterday with a query MI,’ one them said, ‘MI’ being short for a myocardial infarct, or heart attack.
The man was sitting upright in his bed. He looked terrified. His pulse was fast and he was breathing quickly. I put my stethoscope to his chest and listened to his heart and breath sounds. I ran an ECG – an electro-cardiogram which shows the heart’s rhythm. It seemed normal enough to me so I reassured him and told him that there was nothing seriously wrong with his heart
‘There’s something the matter Doc,’ he said, ‘I know there is.’
‘Everything’s all right, you’re just anxious,’ I said a little impatiently, keen to get back to bed. He looked despairingly at me as I turned away. I can still hear his laboured breathing now, the sound following me like an accusation, as I walked away between the rows of beds with their huddled, restless shapes. I can still hear the way in which, as I reached the doors to the ward, his breathing abruptly stopped, and the ward was suddenly silent. I raced back to the bed, panic-struck, to find him slumped in his bed.
‘Put out a crash call!’ I shouted to the nurses as I started to pound his chest. After a few minutes my colleagues tumbled bleary-eyed onto the ward and we spent half an hour failing to get his heart going again. My registrar looked at the earlier ECG trace.
‘Looks like there were runs of V-Tach,’ he said disapprovingly. ‘Didn’t you notice that? You should have rung me.’ I said nothing in reply.
It used to be called angor animi – the anguish of the soul – the fee
ling that some people have, when they are having a heart attack, that they are about to die. Even now, more than thirty years later, I can see very clearly the dying man’s despairing expression as he looked at me as I turned away.
There was a slightly grim, exhilarating intensity to the work and I quickly lost the simple altruism I had had as a medical student. It had been easy then to feel sympathy for patients because I was not responsible for what happened to them. But with responsibility comes fear of failure, and patients become a source of anxiety and stress as well as occasional pride in success. I dealt with death on a daily basis, often in the form of attempted resuscitation and sometimes with patients bleeding to death from internal haemorrhage. The reality of cardio-pulmonary resuscitation is very different from what is shown on TV. Most attempts are miserable, violent affairs, and can involve breaking the ribs of elderly patients who would be better left to die in peace.
So I became hardened in the way that doctors have to become hardened and came to see patients as an entirely separate race from all-important, invulnerable young doctors like myself. Now that I am reaching the end of my career this detachment has started to fade. I am less frightened by failure – I have come to accept it and feel less threatened by it and hopefully have learned from the mistakes I made in the past. I can dare to be a little less detached. Besides, with advancing age I can no longer deny that I am made of the same flesh and blood as my patients and that I am equally vulnerable. So I now feel a deeper pity for them than in the past – I know that I too, sooner or later, will be stuck like them in a bed in a crowded hospital bay, fearing for my life.
