by Adam Kay
‘Now imagine that your anaesthetist accidentally grabs the wrong cloudy fluid off his trolley and injects you with an antibiotic instead of propofol. You’re lying on an anaesthetic table, totally paralysed by a muscle relaxant, but without the propofol you’re entirely awake – able to hear everything that’s being said, able to feel the surgeon cleaning you up with antiseptic and with no way of alerting anyone that something’s gone horribly wrong. You silently scream as his scalpel cuts through your skin – a worse, more searing pain than you’ve ever experienced in your life . . .’ Ron’s expression looks like it’s been drawn on by Edvard Munch. ‘But I’m sure you’ll be just fine!’
* Or indefinitely if you’re Michael Jackson.
Tuesday, 6 June 2006
Called to see a patient in A&E. She had a Medical Termination of Pregnancy a couple of days ago and is in absolute agony. I don’t quite know what the matter is, but something is definitely up – I admit her to the ward for pain relief and senior review. Ernie examines her.
‘She’s having cramping pains. Scan before her MTOP showed an intrauterine pregnancy. Normal. Send her home.’
I try to justify my admission – surely this is way too much pain? She’s on morphine!
‘Only because you prescribed her morphine . . .’
No one is in pain like this with an MTOP, though.
‘How do you know her pain threshold?’ comes the no-nonsense reply. ‘Maybe she’s like this when she stubs her toe as well.’
I venture that something weird is going on here, and he dismisses me.
‘If you hear hooves clip-clopping outside your bedroom window, it could be a zebra. But when you take a look, it will almost always turn out to be a horse.’ He tells me I can prescribe her some antibiotics just in case there’s an infection brewing – but she still needs to go home.
The bleep from the ward saying that the patient had deteriorated would ideally have come at that exact moment. Instead, it came a few hours later, but the result was the same: assisting Ernie in theatre to remove an ectopic pregnancy* and a metric fuck-ton of blood from her pelvis. The scan she’d had before her termination was dangerously wrong.
The patient is now fine and back on the ward. Ernie hasn’t apologized to me, as that would require him to change his entire personality. I’m currently on Amazon, ordering him a key ring in the shape of a zebra.
* An ectopic pregnancy is when an embryo attaches in the wrong place – most frequently in a fallopian tube. Left untreated, they will eventually rupture, and this is the most common cause of death in women in the first three months of pregnancy. Every woman with pain and a positive pregnancy test must be considered as having an ectopic unless otherwise proven by a scan. In this case, the scanner had mistakenly interpreted an ectopic pregnancy as an intrauterine one.
Monday, 12 June 2006
Counselling a patient that weight loss would help control her PCOS,* I refer her to the dietician and ask her about exercise. Just because something is obvious to me, it might not always be obvious to the patient – it feels like knocking on the door of a blazing building to tell the owner their house is on fire, but occasionally it does make a difference. Steeling myself for the predictable answer about a lack of time, I offer: ‘It might help you to join a gym?’
‘I’m a member of one already,’ comes the reply. ‘But I haven’t been in about £3,000.’
* Polycystic Ovarian Syndrome (PCOS) is the most common endocrine condition in women, affecting between 1 in 5 and 1 in 20 females, depending on how they define it, which will have changed another three or four times between me writing this and anyone reading it. PCOS can cause problems with fertility, skin and body hair, and menstrual disturbance.
Monday, 19 June 2006
Called to urgently review an antenatal patient on the ward. Patient ES has begun induction of labour for postmaturity.* The concerned midwife leads me to a toilet on the ward; the patient has just opened her bowels and the pan looks like Lush have released a horrific new red and brown bath bomb. It doesn’t augur well for either the cleaners’ tea break or the patient herself.
I examine her to check the bleeding isn’t vaginal, which it isn’t, and am pleased to see the baby looks fine on the CTG.† The rectal examination was totally normal, the patient says she’s never had anything like this before and has no other symptoms. I send off bloods, crossmatch her, put up some fluids and refer her urgently to gastro. I also google whether Prostin can cause massive gastrointestinal bleeding. There’s no history of it happening before, so this would be the first case – I idly wonder whether they’ll name the syndrome after me. I was rather hoping Kay Syndrome might be a more glamorous discovery than someone shitting themselves inside out during induction of labour, but perhaps it’s a price worth paying for immortalization in the textbooks.
The gastro consultant appears before I’ve finished writing up my notes, and after a quick chat and another lubricated finger, she’s wheeled off for a colonoscopy. Happily, all looks normal and there’s no evidence of recent bleeding. A bit of further questioning and the consultant comes up with the diagnosis: he bleeps to let me know.
The nightmare in the toilet bowl I’d witnessed was in fact the rather damning evidence of the two large jars of pickled beetroot that ES had inexplicably taken it upon herself to eat the night before. Next time I want to refer him someone’s bowel movement, the consultant ‘respectfully’ asks that I taste it first.
* Much like your drunk mate insisting you go on to one more club even though she’s already got vomit in her hair, pregnancies sometimes keep going longer than is wise. After forty-two weeks the placenta can start to give up the ghost, so we induce labour before mums get to that point, the first step being a vaginal pessary such as Prostin.
† The cardiotocograph, known as the CTG or ‘trace’, is a belt strapped to mums during labour that measures and continuously records a tracing of contractions and baby’s heart rate. They are generally described as a ‘reassuring trace’ or a ‘non-reassuring trace’.
Tuesday, 20 June 2006
Our computer system has been upgraded and, as happens eleven times out of ten when the hospital tries to make life easier, they’ve made everything much more complicated. It certainly looks much whizzier (and less like an MS-DOS program from school), but they’ve not actually fixed any of the massive clunking problems with the software, they’ve just slapped an interface on top of it. It’s the equivalent of treating skin cancer by putting make-up over the lesion. Actually, it’s worse than that. This glossy interface uses so much of the exhausted system’s resources that it’s now slowed to a nearly unusable crawl. It’s like treating skin cancer with some make-up that the patient has an extreme allergic reaction to.
The blood tests now all live in a drop-down menu, and to order one involves scrolling down an alphabetical list of every test any doctor has ever ordered in the history of humanity. To get down to ‘Vitamin B12’ takes 3 minutes 17 seconds. And if you press the letter ‘V’ rather than wading down there manually, then the system crashes so badly you have to turn the computer off at the wall and all but use a soldering iron to get it working again. Ninety-nine per cent of the time we order the same dozen tests and yet, rather than prioritizing those at the top of the list (even the easyJet website knows to put the UK above Albania and Azerbaijan), they’re scattered throughout a billion tests I’ve never heard of or requested. Who knew there were three different lab tests for serum selenium? As a result, there’s a very narrow window of anaemic patients I will now order Vitamin B12 levels for. If you’re only mildly anaemic I’m not wasting the day with my finger pressing on the down arrow for three minutes. And if you’re severely anaemic, I won’t order it because you’ll probably be dead by the time I’ve done so.
Friday, 21 July 2006
Bleeped to the gynae ward at 5 a.m. to write a discharge summary for a patient due to go home in the morning. It should have been done during the day by her own SHO and there’s no reaso
n for me to be doing it. But if I don’t do it tonight then it will delay the patient’s discharge. I sit down and get on with it – it’s fairly mindless work so gives me a bit of time to plot some appropriate revenge act on the SHO in question. On my way out, I notice the light is on in patient CR’s side room, so I pop my head in to check if everything’s OK.
I admitted her from A&E last week with tense ascites* and the suspicion of an ovarian mass. I’ve been on nights since and not caught up with what’s happened. She tells me. Suspicion of an ovarian mass has become a diagnosis of ovarian cancer has become confirmation of widespread metastases has become talk of a few months left. When I saw her in A&E, despite obvious suspicions, I didn’t say the word ‘cancer’ – I was taught that if you say the word even in passing, that’s all a patient remembers. Doesn’t matter what else you do, utter the C-word just once and you’ve basically walked into the cubicle and said nothing but ‘cancer cancer cancer cancer cancer’ for half an hour. And not that you’d ever want a patient to have cancer of course, I really really didn’t want her to. Friendly, funny, chatty – despite the litres of fluid in her abdomen splinting her breathing – we were like two long-lost pals finding themselves next to each other at a bus stop and catching up on all our years apart. Her son has a place at med school, her daughter is at the same school my sister went to, she recognized my socks were Duchamp. I stuck in a Bonanno catheter to take off the fluid and admitted her to the ward for the day team to investigate.
And now she’s telling me what they found. She bursts into tears, and out come all the ‘will never’s, the crushing realization that ‘forever’ is just a word on the front of Valentine’s cards. Her son will qualify from medical school – she won’t be there. Her daughter will get married – she won’t be able to help with the table plan or throw confetti. She’ll never meet her grandchildren. Her husband will never get over it. ‘He doesn’t even know how to work the thermostat!’ She laughs, so I laugh. I really don’t know what to say. I want to lie and tell her everything’s going to be fine, but we both know that it won’t. I hug her. I’ve never hugged a patient before – in fact, I think I’ve only hugged a grand total of five people, and one of my parents isn’t on that list – but I don’t know what else to do.
We talk about boring practical things, rational concerns, irrational concerns, and I can see from her eyes it’s helping her. It suddenly strikes me that I’m almost certainly the first person she’s opened up to about all this, the only one she’s been totally honest with. It’s a strange privilege, an honour I didn’t ask for.
The other thing I realize is that none of her many, many concerns are about herself; it’s all about the kids, her husband, her sister, her friends. Maybe that’s the definition of a good person.
We had a patient in obstetrics a couple of months ago who was diagnosed with metastatic breast cancer during pregnancy, and was advised to deliver at thirty-two weeks so she could start treatment, but waited until thirty-seven weeks to give her baby the absolute best possible chance. She died after a fortnight spent with her baby – who knows whether starting treatment a month sooner would have made any difference. Probably not.
And now I’m sitting with a woman who’s asking me if she shouldn’t have her ashes scattered on the Scilly Isles. It’s her favourite spot, but she doesn’t want it to be a sad place for her family once she’s gone. The undiluted selflessness of someone fully aware what her absence will do to those she leaves behind. My bleep goes off – it’s the morning SHO asking for handover. I’ve spent two hours in this room, the longest I’ve ever spent with a patient who wasn’t under anaesthetic. On the way home I phone my mum to tell her I love her.
* Ascites is fluid in the abdomen, and almost always very bad news.
3
Senior House Officer – Post Two
Sometime during my early years as an SHO, I remember watching a documentary about Shaolin grandmasters. They train for a decade or more in a remote temple, waking up at 5 a.m. and only stopping at midnight, submitting themselves to a life of celibacy, devoid of material possessions. I couldn’t help but feel it didn’t sound that bad – at least they didn’t have to uproot their lives every year to a completely different temple.
NHS deaneries, who are responsible for postgraduate medical training, move doctors to different hospitals every six or twelve months to ensure they learn from a broad range of consultants, which I guess makes sense. Unfortunately, each deanery covers a fairly large geographical area, and you get randomly allocated to units throughout that region. For example, one such deanery is Kent, Surrey and Sussex: which I (and indeed the Ordnance Survey) had always considered to be three enormous, separate areas. Another deanery is Scotland. You know Scotland, that – what would you call it, oh yes – entire country measuring over 30,000 square miles. If you’re deciding where to buy your first house, it’s rather difficult to choose a location that’s handy for all of Scotland. Even if you were insane enough to put yourself through a property transaction once or twice a year, it would be fairly tricky as the deaneries limit relocation costs to a princely zero pounds.
So while all my friends in sensible careers were getting mortgages and puppies, H and I were taking on year-long rental contracts and living somewhere mutually inconvenient roughly halfway between our two workplaces. It was yet another item on the list of ways my job was inflicting collateral damage on H – medical widow, post-shift counsellor and now nomad.
I remember once phoning round all the various utilities and DVLA and so on about our change of address (I think as penance because I couldn’t take the day off work to help with the move) and the home insurance people asked a standard question about the number of nights the property is left empty. I realized that if I lived alone, the policy would be invalid as it would technically be considered an ‘unoccupied property’.
Despite the hours, I’d really enjoyed my first year in obs and gynae – I’d made the right choice. I’d gone from a tottering Bambi, terrified every time the bleep went off, to, if not a graceful roebuck, then at least someone who could do a decent impression of one. I now had a bit of self-belief that I could deal with the emergency behind each delivery-room door; mostly thanks to working in a hospital with seniors who were invested in my development as a doctor.
When the deanery rolled their dice for the second time, however, I found myself in a much more old-fashioned hospital. If you describe a grandparent as being ‘old-fashioned’, it’s a euphemism for ‘talks about ordering a Chinky’. In a hospital setting, it means ‘unsupportive’. You’re on your own.
I’d gone from a nursery slope straight to a Schumacher-splattering black run, where they took the now largely extinct approach of ‘see one, do one, teach one’. You’ve watched someone remove a fallopian tube or scan an ovary, so that’s you fully trained up. You’d be forgiven for thinking this was a horrible nightmare. As it turned out at this hospital, it was often the best-case scenario, ‘see one’ frequently getting skipped over, like foreplay in a nightclub toilet tryst.
Nowadays, YouTube instructional videos can show you anything from how to repair an ingrown toenail to separating conjoined twins.* Back in 2006, you had to follow a list of printed instructions in a textbook. To add to the fun, you’d have to memorize these generally quite complicated steps (think kit car rather than IKEA wardrobe) before you saw the patient. How much confidence would you have in someone staring into your genitals with a scalpel in one hand and a manual in the other? I rapidly learned to maintain an air of absolute confidence, no matter how frantically my legs were paddling under the water. In summary, never play poker with me. Although do bear me in mind if you’re struggling with your flat-pack furniture.
Because I spent the vast proportion of my waking hours at work and because the deep end was so very deep, I learned a lot during my second SHO post and did so very quickly. The ‘old-fashioned’ method might not be any fun, but it definitely works. Those Shaolin bastards were basically at holiday c
amp.
* Please don’t attempt either.
Wednesday, 2 August 2006
It’s Black Wednesday* and I have started at St Agatha’s. It is an established fact that death rates go up on Black Wednesday. Knowing this really takes the pressure off, so I’m not trying very hard.
* All junior doctors change hospitals on exactly the same day every six or twelve months, which is known as Black Wednesday. You might think it would be a terrible idea to exchange all your Scrabble tiles in one go and expect the hospital to run exactly as it did the day before, and you’d be quite right.
Thursday, 10 August 2006
Reviewing a mother in clinic, six weeks after a traumatic delivery. All is now well, but something is clearly troubling her. I ask her what’s up and she breaks down in tears – she thinks the baby has a brain tumour and asks me to have a look. It’s very much not my department* but one look at the mother’s collapsed face tells me that now perhaps wouldn’t be the best time to play the unhelpful station assistant at a ticket window and advise she should see her GP. I examine the child and hope that whatever she’s concerned about is within the limited parameters of my paediatric knowledge.
She shows me a hard swelling on the back of baby’s head. My ship has somehow come in and I can confidently announce that this is baby’s occipital protuberance, which is a completely normal part of the skull. Look, there it is on your other kid’s head! There it is on your head!
‘Oh my God,’ she cries, the tears still streaking her face, eyes darting from her baby to her three-year-old and back again, like she’s watching Wimbledon. ‘It’s hereditary.’
* Parents seem to think obstetricians are wise owls with expert knowledge of infants, but this couldn’t be further from the truth. We know the square root of fuck all about them, save for a few half-remembered semi-facts from medical school. Once a baby’s no longer umbilically attached to its mother, we hand them over and never deal with them again until they’re old enough to procreate.
