This is Going to Hurt

by Adam Kay

  * A Venflon, or cannula, is the plastic tube that gets shoved into the back of the hand or the crook of your elbow so we can run drugs or fluids intravenously through a drip. Putting in Venflons is one of the key responsibilities of a house officer, although I got through medical school without ever having tried it. On the night before my first day as a doctor, one of my flatmates in our on-site hospital accommodation stole a box of about eighty of them from a ward and we practised cannulating ourselves for a few hours until we could finally do it. We were covered in track marks for days.

  † Varices are a horrible complication of liver cirrhosis, where you essentially get huge varicose veins inside your oesophagus, which can rupture at any point and bleed heavily.

  ‡ A tube you can wedge down the throat that – when it’s in position – can be inflated like a balloon, to put pressure on the vessels and hopefully stop the bleeding.

  Tuesday, 9 November 2004

  Bleeped awake at 3 a.m. from my first half-hour’s shuteye in three shifts to prescribe a sleeping pill for a patient, whose sleep is evidently much more important than mine. My powers are greater than I realized – I arrive on the ward to find the patient is asleep.

  Friday, 12 November 2004

  An inpatient’s blood results show her clotting is all over the shop for no good reason. Hugo eventually cracks it. She has been taking St John’s Wort capsules from a health food shop for anxiety. Hugo points out to her (and, in fairness, me) that it interacts with the metabolism of warfarin, and her clotting will probably settle down if she stops taking it. She is astonished. ‘I thought it was just herbal – how can it be that bad for you?’

  At the sound of the words ‘just herbal’, the temperature in the room seems to drop a few degrees and Hugo barely holds in a weary sigh. It’s clearly not his first time at this particular rodeo.

  ‘Apricot stones contain cyanide,’ he replies drily. ‘The death cap mushroom has a fifty per cent fatality rate. Natural does not equal safe. There’s a plant in my garden where if you simply sat under it for ten minutes then you’d be dead.’ Job done: she bins the tablets.

  I ask him about that plant over a colonoscopy later.

  ‘Water lily.’

  Monday, 6 December 2004

  All junior doctors at the hospital have been asked to sign a document opting out of the European Working Time Directive* because our contracts are non-compliant with it. This week I have seen H for under two hours and worked for a grand total of ninety-seven. Non-compliant doesn’t quite seem to cover it. My contract has taken the directive, dragged it screaming from its bed in the dead of night and waterboarded it.

  * The European Working Time Directive was brought in to provide some legal measure to stop employers working their staff to their bleary-eyed deaths, by limiting shifts to a ‘mere’ forty-eight hours per week.

  Thursday, 20 January 2005

  Dear drug-dealing scrote,

  Over the last few nights, we’ve had to admit three young men and women – all dry as a husk, basically collapsed through hypotension, and with their electrolytes up the fuck.* The only connection between these individuals is their recent use of cocaine. For all its heart-attacking, septum-shrinking risks, cocaine does not cause this to happen to people. What I’m pretty confident is going on here – and I want a Nobel Prize or at the very least a Pride of Britain Award if I’m right – is that you’ve been bulking out your supply with your nan’s frusemide.†

  Aside from the fact you’re wasting my evenings and my unit’s beds, it feels like fairly terrible business practice to be hospitalizing your customers. Kindly use chalk like everyone else.

  Yours faithfully, Dr Adam Kay

  * Electrolytes are the salts in the blood – mostly sodium, potassium, chloride and calcium. If levels become too high or too low, your body has a way of alerting you, by making your heart stop or putting you in a coma. It’s clever like that.

  † Frusemide, or Furosemide, is a diuretic – if you’ve got a build-up of fluid in your lungs or tissues, generally from a malfunctioning heart or kidneys, it will make you pee it out. If you don’t have a build-up of fluid, as here, it will make you pee out the water content of your blood.

  Monday, 31 January 2005

  Saved a life tonight. I was bleeped to see a sixty-eight-year-old inpatient who was as close to death’s door as it’s possible to be – he’d already pressed the bell and was peering through the frosted glass into the Grim Reaper’s hallway. His oxygen saturation* was 73 per cent – I suspect if the vending machine hadn’t been out of order and I’d bought my Snickers as planned, it would have all been too late.

  I didn’t even have the spare seconds to run through the bullet points of a management plan in my head – I just started performing action after action on an autopilot mode I didn’t know I possessed. Oxygen on, intravenous access, blood tests, blood gases, diuretics, catheter. He started to perk up pretty much immediately, the bungee rope jerking him back from a millimetre above the concrete. Sorry, Death – you’re one short for your dinner party this evening. By the time Hugo arrived, I felt like Superman.

  A strange realization that it’s the first time I’ve actually saved a life in five months as a doctor. Everyone on the outside imagines we roam the wards performing routine acts of heroism; I even assumed that myself when I started. The truth is, although dozens, maybe hundreds, of lives are saved every day on hospital wards, almost every time it happens it’s in a much more low-key, team-based way. Not by a doctor performing a single action, so much as implementing a sensible plan which gets carried out by any number of colleagues, who at every stage check the patient is getting better and modify the plan if they’re not.

  But sometimes it is down to one person; and today, for the first time, it was me. Hugo seems happy, or at least as happy as he’s capable of being: ‘Well, you’ve bought him another couple of weeks on earth.’ Come on – give a superhero a break here.

  * Oxygen saturation is the percentage of oxygen in your blood, and is measured by that little clip they put on the end of your finger. It should be as close to 100 per cent as possible, definitely above 90 per cent, and definitely definitely above 80 per cent.

  Monday, 7 February 2005

  My move to surgery* has rewarded me with my very first degloving injury.†

  Patient WM is eighteen and was out celebrating with friends. After chucking-out time he found himself dancing on the roof of a bus shelter, and then decided to descend to ground level using a handy neighbouring lamp post as a fireman’s pole. He jumped over to the lamp post and slid down, koala-bear style. He unfortunately misjudged the texture of the lamp post – it wasn’t the smooth ride he was expecting at all, but a chafing, agonizing, gritty slump to the bottom. He therefore presented to A&E with severe grazing to both palms and a complete degloving of his penis.

  I have seen a lot of penises in my brief time in urology (and beyond) but this was far and away the worst one I have ever seen. Worthy of a rosette, if only there’d been a place to pin it. A couple of inches of urethra, coated with a thin layer of bloody pulp, maybe half a centimetre diameter in total. It brought to mind a remnant of spaghetti stuck to the bottom of the bowl by a smear of tomato sauce. Perhaps not surprisingly, WM was upset. His distress was only made worse when he asked if the penis could be ‘regloved’. Mr Binns, the consultant, calmly explained that the ‘glove’ was spread evenly up eight foot of lamp post in west London.

  * House officers generally spend six months working in medicine and six months in surgery. The very shortest of straws saw me working in urology.

  † A degloving injury is where skin is traumatically torn from the underlying tissues – typically seen in motorcycle accidents, where the rider’s hands drag along the ground. Rats are able to deglove their tails at will to escape capture. Quite why we were taught this at medical school escapes me.

  Monday, 21 February 2005

  Discharging a patient home after laparoscopy,* I sign her off work f
or two weeks. She offers me a tenner to sign her off for a month. I laugh, but she’s serious, and ups her offer to fifteen quid. I suggest she sees her GP if she’s not feeling up to work after a fortnight.

  I clearly need to dress smarter if that’s the level of bribe I’m attracting. On the way home I wonder how much she’d have needed to offer before I said yes. Depressingly, I put it somewhere around £50.

  * Almost any abdominal operation can now be performed laparoscopically, which is Greek for ‘much much slower’, and involves inserting tiny cameras and instruments on long sticks through little holes. It’s fiddly and takes a long time to learn. Recreate the experience for yourself by tying your shoelaces with chopsticks. With your eyes closed. In space.

  Monday, 14 March 2005

  Out for dinner with H and some mates – a pizza restaurant with exposed brickwork, too much neon, menus on clipboards, an unnecessarily complicated ordering system and the almost total removal of waiting staff. You’re given a device that beeps and vibrates when your order is ready, whereupon you schlep across the artfully mismatched tiles to collect your pizza from a disinterested server who sits there safe in the knowledge that no one ever asks for the 12.5 per cent service charge to be taken off the bill – even when nobody actually serves you.

  The device goes off, I say ‘Oh my God’ and reflexively jump to my feet. It’s not that I’m particularly excited about my Fiorentina – it’s just that the fucking thing has the exact same pitch and timbre as my hospital bleep. H takes my pulse: it’s 95. Work has pretty much given me PTSD.

  Sunday, 20 March 2005

  There’s more to breaking bad news than ‘I’m afraid it’s cancer’ and ‘We did everything we could’. Nothing can prepare you for sitting down a patient’s daughter to explain that something rather upsetting happened to her frail, elderly father overnight.

  I had to tell her that the patient in the bed next to her dad’s became extremely agitated and confused last night. That he thought her father was in fact his own wife. That unfortunately by the time the nurses heard the commotion and attended it was too late, and this patient was straddling her father and had ejaculated onto his face.

  ‘At least it didn’t . . . go any further than that,’ said the daughter, in a world-class demonstration of finding the positive in a situation.

  Monday, 11 April 2005

  About to take a ten-year-old straight from A&E to theatre for a ruptured appendix. Colin, a charming registrar, has been conducting a masterclass in dealing with a worried mum – explaining everything that’s going on her son’s tummy, what we’re going to do to fix it, how long it’ll take, when he’ll be allowed home. I try to absorb his method. It’s about telling her just the right amount – keeping her informed but not overwhelmed – and delivering everything at the right level; not too much jargon, but never patronizing. Above all, it’s about being professional and kind.

  Her expression becomes less uneasy by the second and I can feel the angst leave her body like an evil spirit, or trapped wind. It’s time to take the kid upstairs, so Colin nods to the mum and says, ‘Quick kiss before he goes off to theatre?’ She leans over and pecks Colin on the cheek. Her pride and joy is wheeled away, his own cheek sadly dry.

  Tuesday, 31 May 2005

  Three nights ago, I admitted patient MJ, a homeless guy in his fifties, with acute pancreatitis. This was the third time we’d admitted him with acute pancreatitis since I started this job. We got him comfortable with pain relief and started him on IV fluids – he was sore and miserable.

  ‘At least you get a warm bed for a few nights,’ I said.

  ‘Are you joking?’ he replied. ‘I’ll get bloody MRSA in here.’ It’s come to something when the streets outside a hospital have a better reputation for cleanliness than the corridors within.

  I don’t like to preach, but I’m a doctor and not wanting him to die is kind of in the job description, so I reminded him he’s in here because of alcohol,* and even if I can’t persuade him to stop drinking (I can’t), could I at least ask him to stay off it until we’ve got him out of hospital, as that will really help. This time, it’d be a real bonus if he wouldn’t mind laying off the alcogel dispensers.

  He reared back like I’d just accused him of twincest, telling me that of course he would never do that – they’ve changed the recipe recently and now it tastes really bitter. He pulled me closer to whisper in my ear that in this hospital you’re best off sucking on some of the sanitizing wipes, then gave me a conspiratorial tap on the arm as if to say, ‘that one’s on me’. Tonight he discharged himself ‘home’, but will doubtless be back with us in the coming weeks.

  As per tradition, I celebrate the end of our run of night shifts with my SHO, and go for a slap-up breakfast and a bottle of white wine at Vingt-Quatre. Night shifts are essentially a different time zone to the rest of the country, so even though it’s 9 a.m., you can hardly call it an eye-opener – it’s practically a nightcap. As I’m refilling our glasses, there’s a knock on the window. It’s MJ, who laughs uproariously before shooting me his best ‘I knew it!’ look. I resolve to sit further from the window next time. Or to just have a quick suck on an alcohol wipe in the changing rooms.

  * Pancreatitis is extremely painful, often very severe, and is generally caused by either alcohol or gallstones. There are a number of other causes, and the mnemonic for remembering them, pleasingly, is GET SMASHED. (The second ‘S’ stands for scorpion venom.)

  Sunday, 5 June 2005

  It would be unfair to label every single orthopaedic surgeon as a bone-crunching Neanderthal simply on the basis of the 99 per cent of them it applies to, but my heart does seem to sink with every night-time bleep to their ward.

  So far this weekend I’ve reviewed two of their patients. Yesterday: a man in atrial fibrillation* following surgery for a #NOF.† I note from his admission ECG he was in AF at that point too – a fact completely unnoticed by his admitting team, even though it would almost certainly explain why he ended up sprawled across the floor in Debenhams in the first place. I feel like running a teaching session for the orthopaedic department entitled, ‘Sometimes people fall over for a reason’.

  Today, I’m asked to review a twenty-year-old patient whose blood tests show abnormal renal function. Both his arms are in full plaster casts, like a Scooby Doo villain. He’s got no drip for fluids and an untouched glass of water on his bedside table that – despite all the will in the world, I’m sure – physics has prevented him from touching for the past couple of days. I prescribe IV fluids for the patient, though it would be more efficient to prescribe common sense for some of my colleagues.

  * Atrial fibrillation (AF) means the heart is beating fast, erratically and inefficiently – this isn’t ideal.

  † #NOF means fractured Neck of Femur. If you thought # was a hashtag, you’re banned from reading the rest of the book.

  Tuesday, 7 June 2005

  Assisting in theatres on the emergency list, removing a ‘foreign object’ from a patient’s rectum. Less than a year as a doctor and this is the fourth object I have removed from a rectum – professionally, at least.

  My first encounter was a handsome young Italian man who attended hospital with the majority of a toilet brush inside of him (bristles first), and went home with a colostomy bag. His big Italian mother was grateful in ways that Brits never are, lavishing thanks and praise on every member of staff she met for saving her son’s life. She put her arm round the equally handsome young man who attended hospital with her son. ‘And thank God his friend Philip was staying in the spare room at the time to call the ambulance!’

  Most of these patients suffer from Eiffel Syndrome – ‘I fell, doctor! I fell!’ – and the tales of how things get where can be skyscraper tall (come to think of it, it’s only a matter of time before someone tries to sit on the Gherkin), but today is the first time I’ve actually believed the patient’s story. It’s a credible and painful sounding incident with a sofa and a remote control that at
the very least had me furrowing my brow and thinking, ‘Well, I suppose it could happen.’ Upon removal of the remote control in theatre, however, we notice it has a condom on it, so maybe it wasn’t a complete accident.

  Thursday, 16 June 2005

  I told a patient that his MRI wouldn’t be until next week and he threatened to break both my legs. My first thought was, ‘Well, it’ll be a couple of weeks off work.’ I was this close to offering to find him a baseball bat.

  Saturday, 25 June 2005

  Called to pronounce death* on an elderly patient – he’d been extremely sick, wasn’t for resuscitation, and this wasn’t unexpected. The staff nurse takes me to the cubicle, points out the slate-grey former patient and introduces me to the wife, who you could say isn’t technically a widow until I make the call that he’s officially dead. Nature may do all the heavy lifting, but you still need me on hand to sign the form.

  I extend condolences to the patient’s wife, and suggest she might want to wait outside while I perform some formalities, but she says she’d rather stay. I’m not sure why; I don’t think she is either. Perhaps every moment with him matters, even if he’s no longer with us, or maybe she wants to check I’m not one of those doctors she’s read about in the Mail who does unspeakable things to the deceased. Anyway, she’s settling down in her front-row seat whether I like it or not.

  I’ve pronounced three deaths before, but this is the first time I’ve had a captive audience. I feel I should have laid on refreshments. She clearly doesn’t realize quite how tense, silent and drawn-out this evening’s performance is going to be – more Pinter than Priscilla, Queen of the Desert.