Hospital Babylon

by Imogen Edwards-Jones

  ‘English?’ Mr Lee nods again. ‘Google translate.’

  ‘Google bloody translate!’ declares Chris.

  ‘You just type in what you want to say and it translates it,’ explains Jon Berry from the computer.

  ‘I know what it does!’ says Chris. ‘What it means is we have paid for the flight, board and lodging of someone who can’t communicate with a single patient!’

  Not that being able to speak English appears to be a priority in the NHS any more when it comes to hiring doctors. As members of the European Community we opened our doors to foreign doctors who can practise here without having to sit exams or pass language fluency tests. Only those who live outside the EU have to sit the PLAB (Professional and Linguistic Assessment Board) tests, which means that it is much harder for the NHS to recruit in its old Commonwealth stamping grounds of India, Australia and South Africa, where ironically the inhabitants already speak English, and have been trained in the UK system, or something similar. The result is that the UK is no longer the ultimate destination for doctors all over the world.

  After the Red Army, the Indian Railways and, I think now, Wal-Mart, the NHS is the largest employer in the world and it used to be a Mecca for all aspiring doctors, as unlike many other health services in the world it does not promote nationals over foreign doctors. Once you are accepted into the NHS community, you can rise through its ranks, specialize and get a consultancy, no matter where you came from. It is a remarkably egalitarian place to work; your rights and duties are the same as any other doctor within the system. No one will say ‘You’re from Nigeria, you can’t become an ear, nose and throat specialist.’ Whereas in other countries, even in the EU, they will train and promote their own doctors above others, and even make sure that some of the more lucrative specialisms, such as ENT or facial plastics, are not open to foreign doctors. I had a friend who was born in Damascus who found it impossible to be an ophthalmic surgeon in the US. The only options open to him were paediatrics, general medicine, anaesthesia and pathology – none of which is a big earner, which is why he was allowed to do them.

  You’d be amazed what actually are the big cash jobs within the health service. It is not necessarily the big jobs that earn the big money. What you need in order to earn money in medicine is a high turnover. Quick ops that are low-risk and don’t take much time. Things like cataracts, which used to be difficult but are now quick and easy and, at a grand a pop, a very good line of work to get into. It’s the old widget factory idea. There’s an operation called a stapedectomy, which involves taking a small bone out of the ear and replacing it with a tiny piston, which is quite handy. It takes three minutes and earns the surgeon £500 a go. A colonoscopy is also quite useful. It’s an anal and lower gut examination that takes about twenty minutes; the hospital gets a grand for each one, and the consultant pockets about £300. There are hernia clinics which charge over a couple of grand per hernia. The surgeon will probably get about £300 to £400 per operation. And he will, obviously, be doing a few of those a day.

  There are also the backhanders that doctors get for recommending certain consultants. Say I have a patient who needs a cancerous lump removed from her thyroid. There are numerous ENT specialists I can choose from, but if I have a friend who promises to give me 10 per cent of the fee then why not recommend him? Specialist consultants can’t lobby for patients, they are totally dependent on referrals, which puts them at the unscrupulous mercy of others further down the food chain. And the more specialized and rarefied they are, the more isolated they are from their ‘clients’, therefore the more dependent they are on referrals from their generous colleagues. It is an odd situation.

  Also, you have to remember that the world of medicine is not static; what has feathered a surgeon’s nest nicely for a decade can suddenly change. Bypass grafts used to be the big earner for cardiac surgeons. They would work all day in the NHS, then come six p.m. they’d pop out and do two or three private bypasses at £5,000 each. No wonder, then, that plenty of the big boys were on a million-plus a year. Sadly, statins have ruined that little business. Peptic ulcers also used to be lucrative. It was easy to take things out of stomachs. It didn’t take long and wasn’t tricky, and plenty of people had bleeding ulcers, perforated ulcers, peptic ulcers. Now, of course, they are all treated by pills.

  And the amount of money charged is all so random. No one is really terribly sure why an eye op is £2,500 and a knee op is £1,500. It all boils down to what the insurance companies are prepared to pay. The same goes for the price of a hospital room. The cost of a night in a private hospital or of a private room in a NHS hospital is more or less plucked out of the ether. The overheads, rent and servicing in a NHS hospital are already taken care of – so the £1,000 bill is entirely fictitious. It sounds about the going rate, so it becomes the going rate. No one anywhere can tell you the reason why.

  Not that doctors become doctors to make money. I became a doctor because my father was one and his father was one before him. It’s a family business, as it were, and to say that I was channelled in that direction would be an understatement. I had a skeleton on my bedroom wall as a child and could name all the bones by the time I was seven years old. My dad is a GP and he has a small but grateful practice just outside Reigate. Sadly, he is not one of the four thousand or so GPs who earn ‘more than the Prime Minister’ – like that is the litmus test of importance or indeed value for money. But he does quite nicely, thank you. Having said that, when you hear of some GPs earning over £400,000 a year, you do have to question the system that cuts their working hours by seven hours a week and gives them bonuses for treating certain patients, and results in one savvy spark, Dr Shiverdorayi Raghavan, trousering over a million quid from the NHS in two years from his two Birmingham surgeries.

  But in general, doctors don’t make big money on the NHS. They make a tidy £100,000 and have quite a nice pension as well, but the real money is elsewhere. A surgeon mate of my dad’s who has a large private ENT practice says that he spends four-fifths of his time working for the NHS for one-fifth of his income. His set-up is the Shangri-La for doctors – working for the NHS and having a healthy private practice at the same time. Doctors who ditch the NHS completely in order wholeheartedly to chase the dollar are always viewed poorly by their own profession. Firstly, there is an old-fashioned residual idea that you were trained by the NHS, therefore you owe the system and need to pay it back. And secondly, it is only working within the NHS that you get to do the big operations and learn about the new techniques and hear about the new medical advances. If you are out of the system you tend to fall behind. Mainly because you can’t afford to do the big operations as your facilities aren’t state-of-the-art and your support staff aren’t trained highly enough and you can’t afford the insurance. You can only do the big stuff at the big teaching hospitals, as they are the only places that have properly staffed intensive care units to look after the patients.

  These days, of course, with so many of us doctors sloshing about, private practices are as difficult to come by as consultancy posts. And they are also regional. Only 10 to 11 per cent of the population have private medical insurance, which obviously means that the other 90 per cent do not. So if you want to work in private practice you need to be in the right catchment areas. Jobs and practices in London and the south-east are therefore contested more fiercely than those without a private practice in the north. There was a story going about last year that a plastic surgery patient wreaked revenge on his surgeon for a botched skin graft job by shooting him. Other plastics guys immediately got on the phone, not to send flowers or their condolences, but to find out where the bloke worked. A vacancy is a vacancy after all.

  There are plenty of drawbacks to private practice. It is not all plain sailing towards the £900,000-a-year pay cheque. There’s the £50,000-a-year-plus insurance to pay, as well as the dreary droning on from the clients to put up with. I have a friend who is a neurologist who has several email accounts so that he is n
ot inundated by the ‘worried well’. He gives out certain accounts to certain people who he knows might need a little bit more of his time than others. The attention seekers might find him abroad more often than is strictly the truth, or just that little bit more elusive than other less demanding patients. Private patients call whenever they like, you see. Most think nothing of calling at three a.m. to discuss a headache. My friend says the more they pay, the more they like to talk.

  And, interestingly, as more women are becoming doctors, lifestyle is starting to play a part in the popularity of practices. Whereas before the glamour jobs such as cardiac surgery and plastics were the ones that were oversubscribed, now suddenly the jobs with more sociable hours are topping the lists. Dermatology is currently a favourite. There are very few emergency dermatological call-outs, and the rest of the time you are dealing with patients who make appointments with excellent private practice potential.

  Right now I have a feeling that Chris Williams is rather wishing that he had a private practice to retire to this morning, rather than deal with the diminutive Mr Lee and his inability to understand a bloody word anyone is saying to him. Chris is on the phone to Administration, admonishing them for hiring someone he himself had personally vouched for. While the rest of us try to avoid the prying eyes of Jon Berry and his increasingly persistent questions and dull fascination for four-hour waiting times.

  I have just managed to sidestep his advances and am on my way to grab a swig of water from the cooler in the corner when the double doors crash open and an ambulance crew come steaming in. Chris drops the phone and comes running, grabbing my arm as he passes.

  ‘You!’ he says.

  I follow him into the resus cubicle. The patient, a woman, doesn’t appear to be moving. Her thick blonde hair curls off the trolley in wet clumps; beneath her oxygen mask her mouth is hanging open. When I worked in Geriatrics for six long months, we used to joke about patients lying in bed with their mouths open. There was the ‘O-sign’: the mouth was open and round, which meant that they were alive, just. Then the ‘Q-sign’, when the mouth was open and the tongue was hanging to one side. They were dead. And then the ‘T-sign’, which was the number of undrunk cups of tea sitting beside the bed, which was indicative of how long they had been dead. This woman has an O-sign, which is not good, but obviously better than a Q.

  There are two ambulance crew with her, who are filling Chris, Margaret and me in as we check her over, give her fluids and wire her up to the machines.

  ‘What’s her name?’ I ask.

  ‘Rebecca, Rebecca Benson,’ replies the tallest bloke, with a two-day beard.

  ‘Hello, Rebecca? Can you hear me? Rebecca? Can you hear me? You’re in hospital, Rebecca. If you can hear me, Rebecca, say something.’

  She is pretty, in her early thirties I would say.

  ‘Take my hand, Rebecca. Give it a squeeze if you can hear me.’

  Her hands are slim and her fingernails are painted pale pink. She’s wearing a wedding ring and a diamond engagement ring.

  I pull back her dark curling lashes. Her pupils are blown. They are not responsive to my torch at all. ‘Can you hear me, Rebecca? Squeeze my hand.’ Nothing. She does nothing. She just lies there. She is breathing on her own, but only just. The chances of asphyxia are high. ‘Tube her?’ I ask.

  Chris nods.

  According to the ambulance guys she fell out of the back of a boat as she was going waterskiing this morning and hit her head as she entered the water. Her heart stopped. They’ve administered CPR but they are not sure how long a downtime she has had. Chris pulls back the blanket to look at her chest. She is wearing the remains of a wetsuit which has been pulled back to reveal a yellow bikini top. Her bosom is a mass of red and purple bruising. They tried their best, but sometimes these guys literally punch your chest in order to get your heart beating. But at least her heart is now working; it’s the downtime that’s the problem.

  ‘How long was she down for do you think?’ asks Chris, checking her over for any signs of life.

  ‘The on-site medic at the reservoir had already started CPR when we got there,’ says the taller member of the ambulance crew. ‘He said about three to four minutes.’

  ‘You sure?’ says Chris, running a pen the length of the soles of her feet; her pink painted toes don’t curl. He sticks the point of the pen into her leg. Still nothing. ‘It feels longer to me; she’s not very responsive. What do you think?’ he asks me.

  I look at her slim, active-looking yet lifeless body and I feel my heart sink a little. ‘I think we’ll only really know after the CT scan. It’s hard to tell otherwise.’

  ‘But in your gut?’

  ‘Over five.’

  ‘Let’s hope she believes in God,’ says Chris, scratching his grey hair. ‘Because she is sure as hell going to need him now.’

  11 a.m.–12 p.m.

  Margaret and I accompany Rebecca Benson and two porters up to the intensive care unit. They are two agency nurses short this morning and it’s quicker for us to take her up than wait for them to come down and get her. It is much better for her to be there. They can start running some tests right away and she can go from there for her CT scan which is booked within the hour.

  I have to admit, ICU is one of my least favourite places in the hospital. I’m not sure if it’s the quiet I can’t bear, broken only by the beeping instruments and the bellows-like sound of mechanical breathing. Maybe it’s the lack of movement. No one ever really appears to be in a hurry in ICU. They all creep around in rubber-soled shoes, like a legion of Stepford nurses, no one ever breaking into a run. Stability is the name of the game here, and all they are ever doing is topping up drips or emptying IV bags, keeping people comfortable. The patients themselves don’t move much. Most are in a coma, supposedly undergoing some sort of neurological rehab, which seems to involve just lying there while one relative after another sits by the bedside and hopefully squeezes their lifeless hand. Or they are simply deeply sedated as they recover from traumatic accidents or operations. I find the place incredibly depressing.

  It really is God’s waiting room. It is the last resort, where surgeons send their chronically ill patients in order not to have to deal with their hysterical relatives themselves. Rather than fessing up and admitting that the situation is totally hopeless, that the patient is brain-dead and unlikely ever to recover, they chicken out and pretend there is a chink of light at the end of a very long and very dark tunnel, and that if only their father, mother or son were to spend some time in ICU they might stand a chance. It’s the coward’s way out – passing the buck.

  Another thing about ICU is that the relatives always expect miracles. They’ve seen so many TV shows where people suddenly wake up, have a stretch and a yawn, and the person at the bedside says something along the lines of ‘Hello, Mum, what took you so long?’, that they expect it to happen to them. When in fact it is hard work surviving ICU. You have to be fit. You have to be able to withstand the tubes, the drugs, the muscle-wasting, the inertia. It is difficult for the body to get through something so traumatic. If you were in bad shape before you went in, chances are you are not coming out alive. Only about 5 per cent of cardiac patients walk out of ICU. Actually, only about 10 per cent of patients survive a cardiac arrest full stop, but because of Casualty and ER people expect the majority of cardiac patients to ‘pull through’ in the end. Doctors have also been known to lie to the consultants who run ICU and tell them their patient had a wonderful quality of life before going into ICU, so as to get them a bed. I remember Chris spinning some sort of yarn about an elderly woman a few months back, telling them she’d been up and about, walking to the shops, etc., when in fact she was a bedridden alcoholic whose daughter, visiting her once a day, kept her in sauce. The old biddy had fallen out of bed because she was so sozzled and landed on her head. Amazingly, she did leave the ICU standing on her own two feet, rather than feet first. So maybe Chris was right to lie.

  One other thing that is sho
cking about ICU is the money it sucks in. Each bed costs about £1,800 a day to maintain and is surrounded by around £60,000 of equipment, and there’s a nurse-to-bed ratio of one to one, which means that more often than not, due to the flexibility of numbers on the ward, they use agency nurses who cost on average four times more than the staff. Our ICU ward costs about £25,000 a day to keep open and just over £11.3 million a year. That is extremely expensive, but also, obviously, essential. Last year we had over three hundred operations cancelled at the last minute due to lack of intensive care beds, which of course entails an additional cost that has to be picked up elsewhere within the system.

  We are met out of the lift by the head consultant of ICU. Her name is Jane McRae, and she is notoriously one of the most unpleasant people in the entire hospital. If she has not made a grown man cry by the end of the day, then that day is a disappointment to her.

  ‘Morning,’ she says, her dry mouth cracking into a coffee-stained smile. ‘This our lady?’

  ‘Yes,’ says Margaret, as we both push the trolley along with its various IV stands and monitors. ‘Her name is Rebecca Benson, she is thirty-four years old, and she has had a bump on the head—’

  ‘Downtime uncertain,’ I add. ‘She’s had CPR and we have given her—’

  ‘We’ll take it from here, dear,’ says Ms McRae, tapping the back of my hand, in a manner that implies neither of us is worthy of crossing her threshold. ‘Germs,’ she adds, looking us both up and down.

  I’m not sure if it is by way of description rather than explanation.

  ‘Oh, right, fine,’ I say. ‘I’ll direct her family up here, then, shall I?’

  ‘That would be the simplest thing to do,’ she replies.

  I look her up and down in her pale yellow scrubs, with matching cap and shoe covers. It is hard to be patronizing looking like a great big lemon, but somehow she seems to manage it. It takes effort to harbour that much hatred for the human race. It can’t be doing her much good.