This is Going to Hurt

by Adam Kay

  She hadn’t told me about the contents of the egg either at this point, so there was a moment of confusion for both me and the boyfriend when she asked him to open it. I gave him a pair of latex gloves, sandblasting the very last pico-trace of romance from the scenario. She popped the question and he said yes; presumably out of shock, or fear of what a woman who does that with a Kinder Surprise would do to him if spurned. I wonder where the best man will keep the wedding bands during the ceremony?

  Monday, 17 March 2008

  I’m unsure who decided that junior doctors have so much spare time on our hands that we should conduct annual audits, but the audit meeting is this week, so I’m sitting reviewing patient notes after my night shift, going through the motions like Lady Chatterley in her marriage to the cockless Sir Clifford. As well as collecting my official audit data on APGAR scores* I have spotted an interesting incidental finding, and have put together some data on that too.

  Introduction

  2,500 babies are delivered annually on our unit, of which roughly 750 are caesarean sections. The surgeon records hand-written operation notes for every patient, representing the permanent legal record of the procedure.

  Methods

  I personally reviewed the operative notes of 382 caesarean sections, representing all such procedures performed between January and June 2007.

  Results

  In 109 cases (28.5 per cent) the surgeon performing the procedure has misspelled ‘caesarean’ as ‘caesarian’.

  Conclusion

  In almost a third of cases, my colleagues are idiots and can’t spell the name of the only fucking operation they have to remember the name of.

  * APGAR scores are the standard measure of how well a newborn baby is doing – they get marks for Appearance, Pulse, Grimace, Activity and Respiration. It was devised by a doctor called Virginia Apgar, which makes me think she chose arbitrary measures just because they fitted with her surname. Like if I decided that the best measures of a baby’s health were Kicking, Applauding and Yawning.

  Thursday, 17 April 2008

  Sometimes it’s the little things that make a difference on labour ward. The touch on your arm and a muttered thank you from the mum too exhausted by her labour to speak. The Diet Coke an SHO buys you because you look so knackered. The reassuring nod from your consultant that says ‘you’ve got this’. And sometimes it’s the really massive things that make a difference – like a patient’s husband taking me to one side after an emergency caesarean to thank me, mentioning that he’s head of marketing for the UK operations of a large champagne house and taking my name so he can send me ‘a little something’. I spend a week dreaming of splashing about in a gigantic champagne coupe filled to the brim with prohibitively expensive fizz, like an ostentatious burlesque act.

  Today a package arrived for me at work – and I don’t mean to be ungrateful, but seriously? A branded baseball cap and key ring?

  Monday, 21 April 2008

  Performing an elective caesarean section, assisted by a hungover medical student. With the possible exception of diathermy,* which smells deliciously like frying bacon, the sights and smells of labour ward theatres aren’t great for the morning after. Take a look at the ingredients: there’s over half a litre of blood spilled, plus a tidal wave of amniotic fluid when you cut through the uterus, the baby’s covered in more gunk than you’d find in the plughole of a cattery and the placenta always smells like stale semen – none of which you really want to be faced with when your burps still taste of Jägerbomb and you’re sweating rogan josh through your eyeballs. Baby delivered, and just as I was sewing up the uterus, the student fainted, face-planting right into the open abdomen. ‘We should probably give the patient some antibiotics,’ the anaesthetist suggested.

  * Diathermy is essentially a soldering iron – it heats up the area you touch it on and stops small blood vessels from bleeding by sealing them off. It is important not to clean the skin with alcohol-based antiseptic before the operation, otherwise diathermy sparks can set the patient on fire.

  Tuesday, 13 May 2008

  At a pub quiz with Ron and a few others and one of the questions is ‘How many bones are there in the human body?’ I’m out by about sixty, to the general outrage of my teammates. I try to explain myself: it’s not something you’d ever be taught; there’s no clinical situation where you’d actually need to know this; it’s an irrelevance; I wouldn’t expect Ron to be able to say how many types of tax there are . . . But it’s too late. I can see from the look on everyone’s horrified faces that they’re trying to think back to all the times they’ve asked for medical advice from a doctor who doesn’t even know how many bones there are. Three other teams got the correct answer.*

  * It’s 206.

  Monday, 2 June 2008

  Antenatal clinic. Called in by a midwife to review her patient – a low-risk primip* at thirty-two weeks, here for a routine check-up. The midwife was unable to pick up baby’s heart with the Sonicaid† so wants me to pop in. This happens fairly often, and 99 per cent of the time all is well. I tend to grab a portable ultrasound machine, wheel it in like a hostess trolley, quickly show the parents their baby’s heart on a monitor and then wheel it all back out again, grinning like a gameshow compère. When they’ve had the agony of listening in vain for baby’s heart swoosh-swooshing, all they want is some unequivocal evidence on a screen.

  This is clearly the 1 per cent though, and I can tell as soon as I enter the room. This midwife really knows what she’s doing, and she looks ashen. The patient is a GP, married to an ophthalmology registrar, so we’re in the rare situation where everyone in the room already knows there’s something seriously wrong. I can’t even manage my ‘I’m sure everything’s fine’ speech before I put the ultrasound probe on.

  To make matters worse, I have to call a consultant in to confirm fetal death for the notes, even though both parents know I’ve been looking at the four unmoving chambers of their baby’s heart on the screen. She’s being rational, practical, collected – suddenly in work mode, her emotional shields up as high as mine. He’s in bits. ‘You shouldn’t have to bury your child.’

  * Primip (short for primiparous), meaning first pregnancy. Multip (multiparous) for subsequent pregnancies.

  † Sonicaid is the handheld device that you listen for babies’ hearts with.

  Thursday, 5 June 2008

  The rota has been flinging me around the hospital seemingly at random – from antenatal clinic to gynae theatre to infertility clinic to labour ward to colposcopy to scanning – so everyone feels like a stranger at the moment. I’ve all but given up hope of seeing someone I recognize, unless they’re handing me a latte in Costa.

  It’s especially rare to see the same patient more than once, but on my afternoon round of labour ward I see the GP I’d diagnosed with an intra-uterine death in clinic earlier this week. She’s now in labour, having been induced.* She and her husband seem oddly pleased to see me – a familiar face, someone who doesn’t need an explanation and is already tuned in to what’s happening, can be of some comfort on such an awful, scary day.

  What the hell can you say? It feels like a woeful gap in our training that no one’s ever told us about talking to grieving couples. Will I make it better or worse if I talk positively about ‘next time’? I want to give them hope, but feel like I shouldn’t say it. It’s an extreme version of ‘there are plenty more fish in the sea’ after a break-up, as if babies are totally interchangeable, just so long as you have one. Do I say how sad I feel for them? Is that making it all about me, giving them yet another person’s feelings to consider? They’ll have plenty of their own family members throwing themselves at their feet in misery; they certainly don’t need this from me. How about a hug? Too much? Not enough?

  Stick to what you know. I just talk practically about what will happen over the next few hours. They have a thousand questions, which I answer as best I can. This is clearly their way of coping for now, medicalizing it.

&nb
sp; I pop back every hour or so to see how they’re doing. It goes past 8 p.m., and I decide to stay on labour ward until they’ve delivered. H is expecting me back home any minute but I lie in a text that there’s been an emergency and I need to stay. I don’t know why I can’t just tell the truth. I lie to the patient too when she asks why I’m still here gone 11 p.m. ‘I’m covering for someone,’ I say. It does feel like my presence, if not my conversational skills, are helping them a bit.

  Delivery happens shortly after midnight, and I take blood samples from mum and talk through all the possible tests we can do to find a cause for the stillbirth. They opt for everything, which is understandable, but this means I have to take skin and muscle samples from baby, the worst thing for me in this whole job. It used to upset me so much when I first started that I’d practically have to look away while I did the necessary. Now, slightly more desensitized to a thing you can never quite believe you’ll ever become desensitized to, I can look. I just find it heartbreakingly sad cutting into a dead baby. We expect them to look beautiful, perfect, unspoiled; often they don’t. He’s been dead a couple of weeks, looking at him – he’s macerated, skin peeling, head softened, almost burnt-looking. ‘I’m sorry,’ I say to him as I take the samples I need. ‘There we go, all done now.’

  I dress him again, look up to a God I don’t believe in and say, ‘Look after him.’

  * It’s a terrible cruelty that if a baby dies in utero, the safest place to deliver is on labour ward, surrounded by dozens of mothers and babies.

  Tuesday, 10 June 2008

  Stopped by the police in Holland Park. ‘Did you know you just ran a red light there, sir?’ I honestly didn’t. I’d been driving home on autopilot, utterly exhausted after a relentless night shift that included five caesarean sections. Hopefully I was paying more attention in theatre than on the road.

  I explain to my frontline brothers that I’ve just come off labour ward after thirteen hours. They give not a single shit, a £60 fine and three penalty points.

  Wednesday, 18 June 2008

  I’m no stranger to speaking in code in front of patients. Just a stray word here or there can be the difference between a patient drawing up ambitious plans to build a shrine in your honour and hysterically accusing you of plotting their demise. So we’ve got our equivalent of spelling out W-A-L-K-I-E-S in front of the dog or T-R-I-A-L S-E-P-A-R-A-T-I-O-N to fox an eavesdropping five-year-old.* But it’s not just patients who need to be kept in the dark from time to time. On this job I’ve also had to develop a code so Miss Bagshot can’t understand me, just to survive her interminable consultant ward rounds. When I need a caffeine hit I tell the house officer to ‘review Mrs Buckstar’, and he pops down to Starbucks for me. Three months in and she hasn’t broken this seemingly uncrackable cipher. Either that or she’s turned on by my coffee breath.

  * There are three grades of code. Firstly, there’s the formal Latin and Greek terms for conditions. So, we say ‘dyspnoea’ rather than ‘shortness of breath’ and ‘epididymo-orchitis’ rather than ‘gammy cock and balls’. Secondly, there’s using a layer of euphemism. Instead of suggesting syphilis, we ask to ‘check the VDRL’, which is the lab test involved; rather than saying HIV, we can talk about ‘CD4 deficiency’, referring to the underlying immune problem. Thirdly, and much more fun, are the completely made-up ones that have entered medical vocab in the last couple of decades. They generally sound credible and scientific, and allow you to be frank in front of the patient without them realizing.

  A few of my favourites are:

  Chronic glucose poisoning – Obesity.

  Incarceritis – Onset of symptoms immediately following arrest.

  Q sign – Tongue hanging out of side of mouth, in the shape of a Q. Prognostically-speaking, a very bad sign, though not as bad as the Dotted Q sign, where there’s a fly on the tongue.

  Status dramaticus – Medically well but over-emotional.

  Therapeutic phlebotomy – Gets better after a blood test.

  Transferred to the fifteenth floor – Dead. (NB The number should be one higher than number of floors in the hospital.)

  Friday, 20 June 2008

  I’m teaching the SHO a method of skin closure using staples that I think gives as good a cosmetic result as sutures in a quarter of the time.* He does an excellent job using this technique, but I count at the end that he has used ten staples. I explain it’s bad luck to close with an even number of staples and ask him to put in an extra one in the middle of the incision. I’m not superstitious – I’ll happily limbo under ladders or live in a flat full of open umbrellas – but it’s something I was taught years ago and have passed on to juniors ever since. Science may trump the supernatural, but once someone tells you an operative technique is bad luck, it’s probably better to be safe than sorry. No one wants to be bleeped in the middle of the night because a plateful of intestines have made a surprise appearance out the front of a patient’s abdomen.

  Fully briefed on how to fend off this imminent crisis from the spirit world, my SHO takes the staple gun to insert the final talisman – and accidentally drives a staple deep into the pulp of my finger.

  * Materials and technique in skin closure vary surgeon by surgeon. The staplers, and indeed staples, used are a barely modified version of the kind you’d buy at Rymans.

  Thursday, 3 July 2008

  Patient TH has been telling me for two days now that her breast pump is bugged. I’ve had to promise her that we’ll have it investigated because when I tried to reassure her initially, she started screaming that I was in with the Russians as well. I made my fairly uncontroversial diagnosis of puerperal psychosis,* but failed to persuade the psychiatrists that she was sufficiently unhinged to justify a review. They weren’t convinced she was at risk of endangering herself or her baby. It felt rather like an orthopaedic team refusing to see a patient who had a broken leg on the basis they weren’t due to participate in the New York Marathon.

  Phone call from A&E today – patient TH is currently being reviewed by psychiatry having been brought in by the police. The Starbucks downstairs had phoned 999 after she rocked up, stripped off all her clothes, stood on a table and started singing ‘Holding out for a Hero’. Useful to know where the psychiatrists set the bar.

  * Puerperal psychosis is the nuclear version of postnatal depression – severe psychiatric symptoms in the days after giving birth, occurring in roughly 1 in 1,000 women.

  Friday, 4 July 2008

  Patient NS presents to urogynae clinic for replacement of a lost ring pessary.* She asks if there are options other than the ring type, because they have a bit of ‘baggage’ for her now. She’s fifty-eight years old, and a few weeks ago was dancing at her niece’s wedding, wearing ‘less than substantial’ underwear beneath her dress. Her vigorous Macarena-ing caused the pessary to dislodge and plunge straight down onto the dance floor then happily roll across it, eventually coming to a halt at the feet of the best man.

  ‘What’s this?’ he bellowed, holding it aloft. ‘Has someone’s pram lost a wheel? Oh! Is it some kid’s teething ring?’ The patient departed the dance floor and the wedding before she found out whether or not it got thrust into some poor toddler’s mouth. I offer her a shelf pessary† and a sympathetic smile.

  * A ring pessary is a doughnut of stiff plastic that goes up your vagina and keeps your internal organs, well, internal. Pessaries have existed as long as pelvic organ prolapse, which is to say a couple of years after the first woman gave birth. Historically, a popular type of pessary was the potato – shove it up there and everything stays put nicely. Horrifyingly, the warm and moist environment is an ideal sprouting environment for root vegetables, so they would have to trim the green shoots as soon as they started bristling against their underwear.

  † A shelf pessary looks like one of those hooks you put on the back of your bedroom door to hang your dressing gown on. You get it in or out by holding the hook bit, and the plate section keeps your uterus out of the public eye. />
  Monday, 7 July 2008

  Crash call to a labour ward room. The husband was dicking around on a birthing ball and fell off, cracking his skull on the ground.

  Tuesday, 8 July 2008

  The phrase ‘rollercoaster of emotions’ gets a lot of airtime in obs and gynae but I’ve never seen the big dipper hurtle round its loop quite as fast as today. Called to the Early Pregnancy Unit by one of the SHOs to confirm a miscarriage at eight weeks – he’s new to scanning and wants a second pair of eyes. I remember that feeling only too well and scamper over. He’s managed the couple’s expectations very well, and clearly made them aware it doesn’t look good – they’re sad and silent as I walk in.

  What he hasn’t done very well is the ultrasound. He may as well have been scanning the back of his hand or a packet of Quavers. Not only is the baby fine, but so is the other baby that he hadn’t spotted. Not sure I’ve ever had to break good news before.*

  * Twins occur in 1 in 80 spontaneous pregnancies – they’re more common in IVF because you generally implant a couple of embryos a pop. Chances of triplets are 1 in 80 squared (1:6,400), quads are 1 in 80 cubed (1:512,000) and so on. Almost every complication of pregnancy is more likely the more babies you’re carrying – anything higher-order than twins is generally a bit of an obstetric catastrophe. Although I once had a patient with quads, and I seem to remember she ended up getting free nappies, clothes, baby food and a people carrier by way of sponsorship.

  Thursday, 10 July 2008

  Next week me and H head off for a fortnight in Mauritius, to celebrate five years together. I’m excited about a bleep-free existence and hopeful I haven’t forgotten how to have a relationship that isn’t conducted over hurried breakfasts and apologetic texts.