by Adam Kay
In obs and gynae, it means you’ll frequently be the most senior person in clinic. You’ll lead the ward rounds more often than not. You get to be called Mr Kay rather than Dr – which makes the previous decade of studying feel like a fucking waste of time. You’re expected to teach medical students. You’re expected to perform all but the meatiest of operations. Most crucially, you run the labour ward. There are senior registrars and potentially even consultants available if you hit DEFCON 1, but this is the grade where you’re generally responsible for keeping a dozen labouring mums and babies alive at all times. This one probably needs a caesarean, these two are going to need an instrumental delivery, this one’s haemorrhaging. You become amazing at prioritizing. It’s like you’re living in a constant logic puzzle; the one with the boat, the fox, the chicken and the bag of grain. Except there are a dozen chickens, they’re all delivering triplets and the boat’s made of sugar.
It sounds horrific – and at times it was – but the day I started as a registrar, I had a huge spring in my step. Not since the day I qualified had I felt so optimistic – I was practically shitting confetti. I was suddenly halfway to becoming a consultant, enjoying the Wednesday afternoon of my metaphorical week. Not only was a senior job just a few years away, I could actually picture myself doing it, maybe even doing it well. It felt like everything at work and home was clicking into place, like I’d finally figured out I’d been holding the map upside down all this time. For once my life didn’t seem that depressing compared to non-medic friends. I had a flat, I had a new(er) car and a (more or less) stable relationship. I felt satisfied. Not smug or complacent, but just in marked contrast to the years I’d felt somehow unsatisfied with the way things had been going.
I realized that most of my colleagues weren’t so lucky, especially when it came to their home lives. Mine was largely held together by superhuman levels of tolerance and understanding; most doctors’ relationships crumbled after a year or so – the cracks that they all develop would appear far too early, like some bizarre premature ageing disorder.
Certainly the hours don’t help. After four or five years of intravenous NHS Kool-Aid, staying late, arriving early and filling in for colleagues have become fully formed habits. A widely held belief among non-medics is that there’s some degree of choice involved in coming home at 10 p.m. rather than 8 p.m. But really the only choice is whether you fuck over yourself or your patients. The former is annoying, the latter means that people die – so it’s not really a choice at all. The system runs on skeleton staff and, on all but the quietest shifts, relies on the charity of doctors staying beyond their contracted hours to get things done. It would be against everything you stand for to knowingly compromise patient safety, so you don’t – which means you stay late after almost every shift. Of course, medics aren’t alone in working late – you could say the same of lawyers and bankers – but at least they can become ‘weekend warriors’, letting down their hair and their ancestors in a forty-eight-hour blast of unremitting hedonism. Our weekends were usually spent at work.
But it’s more than just the hours; you’re generally no fun to be around when you get home. You’re exhausted, you’re snappy from a stressful day and you even manage to deny your partner their normal post-work chat of bitching about their colleagues. They know as soon as they start on their workplace quibbles – which presumably don’t involve any near-death experiences, unless they’re a tightrope walker, firefighter or counter staff at a drive-thru Burger King – you’ll reflexively man that old ship One-Up and talk about the horrors of your own day.
Your subconscious ends up making a decision on your behalf. Either you fail to tune out the bad stuff from work and become permanently distracted and haunted at home or you develop a hardened emotional exoskeleton, which apparently isn’t considered an ideal quality in a partner.
A few of my colleagues had kids by this point and lived their lives in constant childcare hell, adding ‘guilt’ to the psychology textbook of emotions that a career in medicine bequeaths you. I don’t have kids, but I could understand what a gut-wrench it was for my colleagues to settle for a goodnight phone call with their children rather than tucking them in and reading them The Gruffalo. Or, more often than not, they’d miss the call altogether because labour ward was in meltdown. A friend who worked in general surgery once couldn’t go along to his own son’s emergency surgery because he was performing non-emergency surgery on someone else’s son and no one could cover for him.
Once I became a registrar, I noticed the interesting paradox that while you become an expert in prioritizing at work, you generally become even worse at prioritizing in real life. But for a while there I felt like the exception who proved the rule – the one guy who had his shit together in some small way, plates all spinning away nicely. Now I just had to make sure none of them smashed . . .
Thursday, 16 August 2007
A horror story. Patient GL, whose genetic make-up appears to be 50 per cent goji berry recipes and 50 per cent Mumsnet posts, has announced she wants to eat her placenta. The midwife and I both pretend not to hear this – firstly because we don’t know what the hospital protocol is, and secondly because it’s completely revolting. GL calls it ‘placentophagia’ to make it sound more official, which doesn’t particularly wash; you can make anything sound official by translating it into the ancient Greek.*
She explains how natural it is among other mammals, which is another somewhat defective argument – we don’t let other mammals do things like run for parliament or drive buses, nor do we normalize other things they do like fucking the furniture or eating their young (or ‘paedophagia’, as she’d presumably call it).
I turn the conversation to the more pressing matter of clapping some forceps on her baby’s head and getting it out. This happens smoothly and baby is fine – and will continue to be until it gets home schooled and taken on all-naked, yurt-based family holidays. A couple of minutes later, I’m delivering the placenta and look up to have the awkward discussion about what GL would like me to do with it. She has a kidney dish in her hands and is shovelling handfuls of blood clots into her mouth.
‘Isn’t this the placenta?’ she asks, blood dribbling out of the corner of her mouth like the disgusting progeny of Dracula and the Cookie Monster. I explain that it’s just some clots I left in a bowl after delivering baby. She turns ashen, then green. Clearly blood isn’t the delicious post-delivery snack she imagines placenta might be. She holds up the kidney dish and vomits into, onto and around it. Sorry, I mean experiences haematemesis.
* ‘Cholelithoproctophilia’ would be shoving gallstones up your arse, but I’ve just made it up. ‘Orbitobelonephilia’ – sticking needles in your eyes. ‘Craniophallic anastamosis’ – dickhead.
Wednesday, 19 September 2007
Email from Head of Administration, Undergraduate Learning Centre:
Dear Adam,
As you know, we are grateful for your commitment to undergraduate teaching. In future when emailing the fourth-year students about teaching sessions, kindly refer to the Undergraduate Learning Centre as the Undergraduate Learning Centre, not the Early Learning Centre.
Tuesday, 2 October 2007
Retrieve my phone from the locker after an unremitting day on labour ward. Seven missed calls from Simon and a bunch of voicemails, all from this morning. I hesitate before pressing play – I know in my heart it’ll be too late already; I’m already half preparing what to say to the coroner. Turns out Simon’s pocket-dialled me, the little bastard.
Wednesday, 24 October 2007
It’s a quiet night on labour ward so I go to my on-call room, lie in bed and piss around on Facebook for a bit. Someone has linked to a bucket list quiz, where you tick off, from a checklist of 100, various things you’ve achieved in your life. Have you visited the Great Wall of China? Ridden an ostrich? Been eaten out by one of Barry Manilow’s security team in a Las Vegas infinity pool? It turns out I’ve done very few things at all. I check my emails, then
have a wank.*
Mid-wank, the crash bleep† goes off. Scrub trousers back on, I rush into a delivery room – the mother is pushing and there’s an extremely worrying CTG. Within a minute of walking into the room I have delivered the baby by forceps extraction. Mother and baby both fine, good old me. I can now write my own bucket list and tick off ‘Delivered a baby while still erect’.
* I don’t know what the GMC position is regarding wanking in on-call rooms. An email to them asking for clarification sat unsent in my drafts folder for over a month when I was putting this book together, before I chickened out and deleted it. But we’ve all done it. Basically, make sure your doctor uses the hand gel when he rushes into your room at night.
† For life or death emergencies, you can be summoned by a ‘crash bleep’ – your bleep is granted the power of speech and tells you exactly where to run to, saving valuable seconds.
Thursday, 1 November 2007
I’ve barely started an emergency caesarean when my SHO bursts into theatre to tell me that a patient in another room has a non-reassuring trace and might need an instrumental delivery. My senior registrar is performing some complicated and repulsive emergency gynae op in main theatre and this SHO is a GP trainee on a six-month placement, so it’s my show entirely. I get her to take a photo of the CTG on her phone so I can see how bad it is and attempt to construct some sort of a plan.
By the time she pops back to theatre, I’ve delivered the baby and am starting to sew up the uterus. The trace is much worse than the SHO described, and I have another fifteen minutes of needlework still to go. I put in another stitch to stop the uterus bleeding and ask the scrub nurse to rest a large wet swab over the patient’s open abdomen (leaving her looking like a horrendous Tellytubby) then make my apologies and run off to perform a quick forceps delivery on the other baby. I’ve barely got the tongs off its head when the emergency buzzer blares from the room next door. Another grotty trace, this time needing a ventouse extraction, then management of a post-partum haemorrhage afterwards for good measure.
By the time I get back to theatre to polish off my original caesarean it’s nearly ninety minutes later, and when that one’s done, it’s time to hand over to the morning registrar. I tell him my tale of super-heroism, expecting him to suggest they rename the hospital after me. All I get in reply is a ‘yeah, that happens’, like I’ve mentioned the coffee shop has run out of pains aux raisins.
Monday, 5 November 2007
Patient in antenatal clinic told me she was taking Dorothy every morning because she was feeling stressed. Who’s Dorothy? Some great aunt she was escorting down to the shops as a strange kind of chill-out exercise, like a mental health assistance dog? She informed me Dorothy was the street name for ketamine.*
‘Does it help with the stress?’ I asked – and was genuinely interested in the answer.
* Other terms for ketamine include K, Kit Kat and Special K. Although if she’d told me she was having Special K every morning I may well have missed the reference.
Monday, 12 November 2007
All surgical staff have been summoned to the Early Learning Centre for a lecture on patient safety. Last week a patient had their completely healthy left kidney removed, leaving them only with a completely useless right kidney.
We’re reminded that in the last three years, neurosurgeons in this country have drilled holes in the wrong side of patients’ skulls fifteen times. Fifteen times they couldn’t tell left from right with a Black and Decker at your bonce. Feels like grounds for retiring the ‘it’s hardly brain surgery’ maxim.
The hospital is very keen mistakes like the great kidney snafu aren’t repeated – although it’s slightly too late for this poor guy, whose ashes have presumably just been scattered on the wrong beach.
The upshot is that new hospital protocol states any patient going to theatre must have a large arrow drawn in Sharpie pen on their left or right leg as appropriate. I put my hand up and ask what happens if the patient already has a tattoo of an arrow on the wrong leg. Decent laugh from the lecture theatre and my consultant calls me a fucking clown.
Tuesday, 13 November 2007
I receive an email from Dr Vane, Director of Clinical Governance, advising that if a patient has a tattoo of an arrow on either leg, then it should be covered up with Micropore tape and a new arrow drawn in Sharpie on the correct leg. This will now be included in the policy document, and he thanks me for my valuable contribution.
Tuesday, 8 January 2008
The population is getting fatter faster than a mobility scooter hurtling towards Greggs at closing time. Today our labour ward operating table is being replaced for the second time in as many years, because last month a woman exceeded the weight capacity for the recently acquired ‘obese table’.
I realize it’s a complicated issue, but surely being so big that special equipment has to be ordered in for you would be the first clue that now would be a good time to offload some timber.
The even newer table has enormous wings that flap up from the sides to prevent ‘overspill’, like an industrial version of the dinner table that grandma can extend at Christmas to fit on all the extra vol-au-vents. I reckon you could comfortably rest the Cutty Sark on it – it took ten men, some hydraulic equipment and the best part of two hours to get it into theatre. I presume the next issue will be the table crashing through the floor one day mid-caesarean, killing the entire dermatology department beneath us.
Saturday, 19 January 2008
Today I tipped into full-blown Stockholm Syndrome and decided to go into work on a Saturday off. ‘If you’re having an affair you can just tell me, you know,’ H said.
I performed my first TAH BSO* yesterday and wanted to check the patient was doing OK. Every time my phone buzzed this morning I assumed it was a message from the weekend team to tell me her wound had exploded or I’d punctured her bowel, severed a ureter or let her quietly bleed to death internally. I basically just needed a bit of reassurance to stop myself going insane.
Obviously, she was absolutely fine, and had already been reviewed by my colleague Fred. I immediately felt bad – I’d hate him to think I didn’t trust him to do his job properly (which I don’t), so I nimbly hurried off the ward in order to escape unnoticed. Or not so nimbly – I bumped into him on my way out and had to pretend I was ‘just passing by’, so thought I’d check she was OK.
‘Don’t blame you,’ Fred said, shrugging, and told me his first major op died in hospital. He’d reviewed her obsessively and planned her post-op care meticulously. Then, on the day she was meant to go home, she choked to death on an egg and cress sandwich.
I’m now half considering making my patient nil-by-mouth until discharge, just to be on the safe side. Having ‘just passed by’, I begin the hour-long drive back home and think about what H said earlier. Even if I wanted to have an affair, I honestly think I’d be too tired to unzip my trousers.
* Total abdominal hysterectomy and bilateral salpingo-oophorectomy is the removal of the uterus, cervix, tubes and ovaries. Salpingo-oopherectomy has three ‘o’s in a row, which has to be some kind of record?
Tuesday, 26 February 2008
About to perform a hysteroscopy* on patient FR and as I’m talking through the procedure, she asks, ‘What’s the worst that could happen?’ Patients ask this all the time, and I wish they wouldn’t because obviously the truthful answer is they could die. In her case, as with almost everyone who asks this, the chances of death are infinitesimal, but the question forces my hand into name-checking the Reaper immediately before their operation.
For the past few months, whenever someone has asked, ‘What’s the worst that could happen?’ I’ve replied, ‘The world could explode.’ This generally has the effect of making the patient realize they’re catastrophizing, and breaks the ice a little. Plus, it’s not a lie – one day it will, and doubtless I’ll be working on labour ward when it does.
On this occasion, FR is a fervent believer that the world is going t
o end in the next five years and invites me to a David Icke† lecture at Brixton Academy next week. I might even go. What’s the worst that could happen?
* Putting a camera inside the uterus. One of the mainstays of gynaecology investigations – principally for abnormal bleeding, but also a traditional procedure if you don’t really know what else to do. The procedure was first performed in 1869, and most units haven’t bought new equipment since.
† Icke is a professional conspiracy theorist and Holocaust denier, who puts on inexorably long, mad speeches. By the time this book is published he’ll no doubt be foreign secretary.
Friday, 29 February 2008
Special occasions tend to call for patients to insert special types of object into their vaginas and recta. Christmas in particular has rewarded me well, with a stuck fairy (‘Do you want it back?’ ‘Yeah, bit of a rinse and she’ll be grand’), a grossly swollen vulva from a mistletoe contact allergy and mild vaginal burns from a patient stuffing a string of lights inside and turning them on (bringing new meaning to the phrase ‘I put the Christmas lights up myself’). This is my first leap year working as a doctor and the Great British public have pulled it out of the bag for me with a very, very specific injury.
Patient JB decided to take advantage of tradition and propose to her boyfriend – going to the expense of buying an engagement ring, the trouble of putting it inside a Kinder Surprise egg and the imagination of inserting it vaginally. She would suggest some finger-work to her partner, he would discover it, retrieve it, and then she would go down on one knee (and, presumably, him). Equal parts unexpected, disgusting and, I suppose, romantic. Unfortunately, he was unable to retrieve it as planned – it had rotated itself lengthwise – and no amount of shoogling from either of them would get this particular goose to lay her golden egg. Remarkably, she was so keen to maintain the surprise she wouldn’t tell him what she’d done or why, but eventually decided this was a hospital matter, so we met in cubicle three. It was a very easy delivery with a pair of sponge-holding forceps.
