This is Going to Hurt

by Adam Kay

  The problem with being in a bubble is that it only takes one prick to burst it. It comes in the form of an email from medical staffing, letting me know I now need to work the middle weekend. None of my colleagues can swap with me and I don’t know how to deliver babies over Skype, so I go back to medical staffing to explain my predicament. I have the kind of sinking feeling you’d have going to the headmaster’s office to deny you stole liquorice from the tuck shop, with teeth stained carbon-black.

  I know colleagues who’ve had to cut honeymoons short and miss family funerals, so the odds were never great for them bending the rota for a holiday. They refuse to organize a locum – their best suggestion is that I pop back to England for a bit. I don’t think I’ll get away with breaking this one to H by text message.

  6

  Registrar – Post Two

  I would always feel tremendously proud to say that I worked for the NHS – who doesn’t love the NHS? (Well, apart from the Secretary of State for Health.) It’s unlike any other national asset; no one talks in fond tones about the Bank of England or would think any less of you if you suggested suing Cardiff Airport. It’s easy to work out why: the NHS does the most amazing job and we’ve all benefitted from it. They delivered you when you were born and one day they’ll zip you up in a bag, but not until they’ve done everything that medical science will allow to keep you on the road. From cradle to grave, just like your man Bevan promised back in 1948.

  They fixed your broken arm on sports day, they gave your nan chemo, they treated the chlamydia you brought back from Kavos, they started you on that inhaler, and all this wizardry was free at the point of service. You don’t have to check your bank balance after booking an appointment: the NHS is always there for you.*

  On the other side of the fence, knowing you were working for the NHS took the sting out of so many things about the job: the vicious hours, the bureaucracy, the understaffing, the way they inexplicably blocked Gmail on all the computers in one hospital I worked at (thanks, guys!). I knew I was part of something good, important, irreplaceable, and so I did my bit. I don’t have an amazing inbuilt work ethic, it’s not applied to anything I’ve ever done since (as my publisher will attest), but the NHS is something special, and the alternative is horrifying.

  We should see the skyscraper-high bills of America as the ghost of Christmas future when it comes to NHS privatization. Politicians may act dumb, but they’re not, and we’ll be lured very stealthily into this particular gingerbread house. We’ll be promised it’s only little corners of the NHS that are changing, but there’ll be no trail of breadcrumbs to help us find our way back through the forest. One day you’ll blink and the NHS will have completely evaporated – and if that blink turns out to be a stroke then you’re totally screwed.

  My opinion of private healthcare in the UK changed a bit during my time as a registrar. I used to be on board with it, seeing it as much like private schooling: a bunch of rich people who save the taxpayer a few quid by going off and doing their own thing, no harm done. I could always see myself doing the odd bit of private work as a consultant – one evening a week in clinic maybe, the occasional hysteroscopy list if I thought I deserved a Mercedes, perhaps a caesarean a month if I thought my Mercedes deserved a chauffeur. I knew consultants who had this life, and it didn’t hurt my motivation to imagine it for myself.

  And then in my second year as a registrar I started doing regular locum work. I’d rather overstretched myself on the mortgage and it felt like a sensible way of making my income do at least a reasonable impression of my outgoings. As free time was in short supply (and what I had of it didn’t just feel like mine to give away), I generally took night shifts sandwiched between normal days at work and, in order to guarantee an hour or two of sleep, I would do them in private hospitals or private wings of NHS hospitals, where the workload is a lot lighter.

  These days I get asked fairly often by friends who’ve made much better life choices than me about whether they should have their baby privately. These are people who order from the bottom of the wine list to get a better wine, or order from the bottom of the holiday home in the Chilterns list to get a better holiday home in the Chilterns. People who know that while money might not buy you happiness, it certainly buys you nicer stuff.

  This theory, it turns out, doesn’t really work with childbirth. It’s a shame, because if you choose to go private you’ll be spunking around fifteen grand on it, and it won’t be covered by your health insurance. You’ll definitely get a nicer hospital room and nicer food. You’ll certainly get an elective caesarean if you ask for one. In fact, your consultant might actively encourage you to have one. They can bill you extra for it on top of the fifteen grand – plus they know they won’t get unexpectedly bleeped in the middle of a dinner party to pull a baby out of you. And if you start to bleed a few hours later, when your consultant is back home, the resident doctor will run along. When it was me, fine – I could deal with it, it was my day job. But I could see the rest of the rota; and a lot of my colleagues in private-locumland normally worked as SHOs, some of them extremely junior ones, and would be woefully under-equipped to deal with a situation like that.

  But what if there’s a major emergency, beyond any single doctor’s capabilities? One where you need a team of obstetricians, anaesthetists, paediatricians, maybe even medics and surgeons from other specialties? Then all you can do is call 999, have your patient taken to an NHS unit designed to cope with this scenario and hope they live long enough to get there.

  You can google the names of private maternity units alongside the words ‘out of court settlement’ if you want case studies. As I say, the food’s always excellent. Whether it’s to die for is your decision.

  Personally, I didn’t ever want to risk being the doctor holding the ball when it all went wrong, so I bailed on private medicine after a few months of these shifts. Which was a bit of a shame as I’d already decided what colour uniform my chauffeur would wear.

  * For now, at least.

  Saturday, 9 August 2008

  Non-medic friends are always impressed when I perform spot diagnoses on members of the public – like an advanced level of ‘I Spy’. The lady on the bus with early Parkinson’s, the man at the restaurant with lipodystrophy from HIV medication, the guy with the eye changes denoting high cholesterol, the characteristic flapping hand of liver disease, the fingernail changes of lung cancer.

  But there’s clearly a time and a place. ‘Trichomonas Vaginalis,’ I say proudly, pointing out the telltale green discharge residue on the stripper’s vulva. And just like that, I’m ruining the stag do, apparently.

  Monday, 11 August 2008

  Moral maze. On a locum shift in a unit with some private labour ward rooms, and called in by the midwife to see a woman who is pushing and has a worrying trace. I let the patient know I need to give her baby a hand coming out because its heart rate has dropped quite a bit. I tell her there’s no time to wait for her consultant to come in, but it’s literally my bread and butter, and everything will be absolutely fine. She understands.

  Out of the room I call her consultant, Mr Dolohov, a traditional courtesy with a private patient. He isn’t very courteous in response. He says he’s only a minute away and coming straight over: under no circumstances am I to deliver ‘his’ patient. I go back into the room and prepare everything for his arrival – forceps, delivery pack, suture set. And then I decide this is ridiculous; the baby is clearly unwell and will deteriorate every moment I don’t deliver it. What if he’s only a minute away like every minicab is ‘only a minute away’? If the baby comes out compromised because of my inaction, that’s my GMC number up the fuck. And worse, it’s a damaged baby. If this Mr Dolohov wants to complain about me, the worst that can happen is I never work again in a hospital I now have no desire to work in.

  I deliver the baby – it takes a moment to breathe but soon perks up, and cord gases* confirm I was right not to wait. I deliver the placenta, stitch up a graze, clean
up the patient and say, ‘Adam’s a good name.’ She’s calling it Barclay, naturally. Still no consultant. Moral maze correctly navigated.

  I’ve already got changed into fresh scrubs by the time Mr Dolohov finally appears. To give him credit, he’s heard the cord gases from a midwife and gives me a huge apology. I’d have preferred it if he’d given me a huge sum of money, especially as he’ll be charging the patient thousands of pounds for the delivery that I did, but there you go.

  * After the baby is born and handed over to the paediatricians, you take a sample of blood from the bit of umbilical cord attached to the placenta, known as ‘cord gases’. They get tested on a machine on labour ward and definitively show how urgently the baby needed to have been delivered.

  Friday, 5 September 2008

  ‘Do you have a place?’ asked Mr Lockhart as I joined him in morning antenatal clinic. It took me a moment – we’d been talking about holidays, how I’d finally booked one and was off to France with H.

  ‘Yes . . . I mean, we’ve booked our tickets . . .’

  ‘No! A place! Do you have a little place there?’

  How deliciously out of touch he was with the life of a registrar. I can barely afford the mortgage on a tiny flat despite our two incomes; a bolthole in France seems as likely a next move as buying a racehorse or a timeshare on the Death Star. But on the other hand, this is clearly a normal thing for a consultant to have – an aspirational light at the end of the registrar tunnel.

  He apologizes for the fact that he’s going to have to leave clinic a little early today – in fact, he should probably leave now. There are fifty-two patients in clinic and I’m now the only doctor here. There may well be a light at the end of the tunnel, but the tunnel is eighty-five miles long, crammed full of impacted faeces, and I have to eat my way out of it.

  Thursday, 11 September 2008

  I almost cry at the end of an unforgiving night shift when I see my pigeonhole has something other than a nit-picking memo about parking or hand gel; it’s a lovely card from a patient. I remember her well. I repaired a tear she sustained a couple of weeks ago during a spontaneous vaginal delivery.

  Dear Adam,

  Just wanted to say thank you. You did a fantastic job – my GP checked my stitches and said you could hardly tell I’d had a baby, let alone a third-degree tear! I’m extremely grateful to you. Thank you again.

  Everything about it is so thoughtful, the kind of thing that makes the whole job totally worthwhile. She’d even made it herself – beautiful textured white card adorned with her baby’s footprint in gold paint on the front. Then again, I guess she didn’t have much choice – there can’t be much call in Paperchase for ‘Thanks for mending my anus!’ cards.

  Tuesday, 16 September 2008

  In labour ward triage a woman is furious that three or four people who arrived after her have been seen before her. ‘If I ever have to go to hospital, madam,’ one of the midwives calmly tells her, ‘I want to be seen last. Because that means everyone else there is sicker than me.’

  Thursday, 18 September 2008

  My phone rings at 8 p.m. I try to guess whether it’s because I’ve forgotten to turn up for a night shift or someone else has failed to turn up for one and I’m about to get pulled back to the ward on my invisible bungee rope. Happily, it’s just my friend Lee, although he sounds rather worried. Lee is reliably my calmest, least flappable friend, so it’s alarming to say the least. He works as a criminal defence lawyer, and I regularly hear him talking on the phone with policemen, judges and the like, cheerily asking, ‘And was the whole body destroyed by the acid or just the skull?’ or ‘Roughly what size of genocide are we talking?’ He asks if I’m free to come over; his flatmate Terry has injured himself and Lee suspects he may benefit from going to hospital, but would value my advice. It’s not far away and I’m not doing anything that can’t wait, so I pop over.

  Terry has indeed injured himself. From the most insignificant of actions can come the most serious of consequences – and we’ve gone full ‘butterfly effect’ here. He cut his thumb opening a humble can of beans, has severed a little artery that’s currently irrigating the floor and the top of his thumb is flapping open like a Muppet’s mouth. There’s even bone visible. I’m happy to provide my professional assessment that a visit to hospital is not just advised, but is both crucial and urgent. I suspect very few people in the world would disagree with me on this point. Unfortunately, Terry is one of them.

  Lee takes me into the kitchen for a moment. Terry will take quite some persuading to go to hospital – he drinks rather heavily and worries that any blood tests will show liver damage and lead to a cascade of investigations and misery he has no interest in. It would also explain why he was bleeding so heavily and why the expression ‘blood is thicker than water’ didn’t seem to apply to him.*

  I spend a short while trying to negotiate with Terry. I suggest the doctors will be too concerned with the fact half his thumb is hanging off to bother delving too far into anything else, but it’s clearly not a fight I’m going to win. He won’t even let me call an ambulance so they can come and assess him. I go back through to Lee to formulate a Plan B, while Terry ruins a couple more tea towels. Plan B comes quite easily. I’m a doctor, Lee’s a lawyer; between us we can section Terry under the Mental Health Act on the basis that he’s a risk to himself. Lee, clearly knowing rather more about the Mental Health Act than I do, points out that not only can we definitely not section a patient between us, but he wouldn’t be a candidate for it anyway, as he’s completely competent† to make the decision not to go to hospital.

  Lee has a Plan C, which is presented to me in the form of a small crate of medical supplies. A year ago he took a holiday in Uganda (who actually does this?) and the advice given to plucky travellers is to buy one of these kits before you leave and keep it with you while you’re away. If you get hospitalized during the trip, they can use your equipment rather than theirs, and you’ll protect yourself from some hospitals’ slightly laissez-faire attitude to infection control and a dose of HIV.

  Lee unseals the case, opens it out in front of me like a dodgy market trader and asks me if I have what I need to sew Terry back up. He clearly splashed out on the deluxe package – there’s probably enough kit in there to take out a lung. After a short while cooing over it like an auntie trying to find the hazelnut swirl in a box of Milk Tray, I select suture material, scissors, needle-holders, swabs and cleaning solution – the only thing missing is some local anaesthetic. Lee jokes that Terry can just bite down on a wooden spoon.

  And so, five minutes later, I find myself operating on a remarkably up-for-it Terry at the kitchen table. I clean the wound, place some big deep stitches to try and stop the arterial bleeder, then start closing the thumb up in layers as soon as everything’s dry. The pain quickly gets a bit much for Terry to tolerate and – eager to keep his screams to a minimum (if the neighbours pop in to check everything’s OK, this will all take some explaining), Lee hands him the wooden spoon. And it works remarkably well.

  I soon close up the skin and am rather pleased with the cosmetic result. I’m not sure how receptive Terry is to my advice on wound care and removal of stitches, but I give it anyway while he shivers his thanks and reaches for a drink, resolving never to eat beans again. I quietly ask Lee about the medico-legal implications of the evening’s events. He laughs and swiftly changes the subject, packing me off in a cab with a nice bottle of rum. (Presumably Terry’s.)

  On the way home, I realize Terry should probably have a few days of antibiotics, given the slightly backstreet nature of the procedure. I call Lee to make sure he sends Terry to the GP in the morning. I apologize for not writing a private prescription, but it’s against GMC guidance to prescribe for friends and family. I can hear Lee’s eyes rolling over the phone line. ‘I think that’s the least of your worries here.’

  * Among the liver’s many and confusing functions, it produces a whole load of clotting factors, meaning that liver
failure causes defective clotting.

  † A patient is competent to make a decision if they can be demonstrated to understand the information they’re being presented with, retain that information and weigh up the pros and cons. Even if their decision is absolutely bananas.

  Thursday, 16 October 2008

  Handing over an extremely busy labour ward to a locum. We’ve been working flat-out all day, and it’s not going to be a quiet night either. There are a couple of women likely to end up with sections, a couple more heading towards instrumental delivery, plus a busy triage and A&E referrals Jenga-ing up. I apologize profusely – busy shifts are twice as difficult when you’re a locum and don’t know the peculiarities of a hospital. I can sense there’s all sorts of inner turmoil going on behind his eyes, but he says nothing.

  I realize I may have made it sound a little too ghastly, so back-pedal slightly. ‘Room five might deliver normally, actually, and I don’t think there’s anything too urgent in A&E just now, so . . .’ This doesn’t seem to have done the trick – he still looks terrified. He asks me in broken English if he’s expected to do caesareans. I suspect he’s asking whether the SHO he’s on with can operate, and I explain that she’s very junior. But, no, he’s asking if he might have to do a caesarean tonight – he’s never done one before.

  I ready myself for the explanation of what is clearly a hilarious misunderstanding. Maybe he’s meant to be working as a neurology registrar and has just turned up on the wrong ward, and our real locum – the one who can actually do what we need them to do – is just about to stroll in, blaming some confusing signage. Nope, this guy accepted a shift from the locum agency as an obstetric registrar and no one there or at the hospital bothered to ask whether he’d ever worked on a labour ward before.