This is Going to Hurt

by Adam Kay

  I send him home and call the consultant to ask what to do, knowing full well the answer involves me working another twelve hours for free.

  Monday, 20 October 2008

  Patient HT has absolutely nothing wrong with her, physically at least. She’s had normal blood tests, normal swabs, a normal hysteroscopy and a normal laparoscopy. There’s no gynaecological (or any other kind of logical) cause for the pelvic pain she describes, and she’s had no benefit whatsoever from the myriad treatments we’ve tried.

  She still insists it’s gynae. ‘I know my own body!’ She even knows the exact treatment she would like – for us to remove all of her pelvic organs. I and various colleagues and bosses have explained at length that we don’t think it will help her symptoms in the slightest – plus it would be a big operation that carries non-trivial risks, including the chance it would cause adhesions* and result in worsened pelvic pain. She’s adamant it’s the only answer ‘as I’ve been saying all along’, and won’t contemplate any options other than ripping out all of her plumbing. Maybe she’s run out of storage at home and just wants to clear some extra space?

  It falls to me to finally discharge her from clinic and refer her to the pain management service, who will eventually get her on anti-depressants. This doesn’t go down well, and I get everything from ‘I’ve paid taxes all my life!’ to ‘Call yourself a doctor?’ plus a list of all the people she’s going to complain to, from the chief executive of the hospital to her MP. I tell her I appreciate her frustrations, but I really think we’ve done all we can for now. She asks me for a second opinion and I tell her she’s already seen a large number of our doctors, all of whom were of the same opinion.

  ‘I’m not leaving here until I’m booked in for this operation,’ she announces, hands folded in her lap, and she clearly means it. I don’t have time to wait for Satan to put on gloves and a North Face jacket, so I decide to book her in for another appointment in a few weeks’ time – throwing a colleague under the same bus I’ve just dodged the fare on. I’ve got no doubt she can, and will, waste this clinic’s resources for another year or more.

  Before I offer her this appointment, she screams, ‘Why does no one take me seriously?!’ then picks up a sharps bin† and throws it at my head. I yelp, duck and constrict my anus to a one millimetre bore. The bin hits the wall above my desk and a shower of virulent needles rains down around me. Somehow, like Roadrunner escaping a Wile E. Coyote assassination attempt, they all miss me, and I avoid catching twelve strains of HIV. A nurse runs in to see what the kerfuffle is and then goes to phone security. And with that the patient is discharged from clinic. Next!

  * Adhesions are bands of internal scar tissue, caused by previous operations or sometimes infections. They can cause pain for the patient, and also make subsequent operations much harder by gunking together all the organs. It’s not always perfectly laid out in there like steaks and sausages on an OCD barbecue, you know.

  † Every office has separate bins for general rubbish, paper, plastics, etc., for everyone to ignore. In medical settings we also have the sharps bin – rigid plastic sweet tubs where you dispose of used needles, blades, lancets and the like.

  Thursday, 6 November 2008

  I have lost a pen. Or more accurately, my pen has been stolen. Or even more accurately, it has been stolen by one of the three people in delivery room five: patient AG, her boyfriend or her mother. I wouldn’t mind so much were it not a birthday present from H, were it not a Montblanc and had I not just delivered their baby.

  The labour itself was without serious incident but they’ve been aggressive throughout my time with them and their feral snarling matched with the considerable tattoo count – baby excluded, for now – makes me slightly reluctant to accuse them of larceny.

  I guess I’m lucky to have made it this many years without something getting pinched. Colleagues have had everything from scrub pockets picked, bags nicked from the nursing station and lockers broken into; not to mention tyres slashed in hospital car parks and even the odd physical assault.

  I have a moan to Mr Lockhart, who I wouldn’t trust to cut a patient’s toenails, but is always good for a bit of advice and an anecdote. The advice was to forget it, don’t get stabbed, and fair play to the patient for recognizing a decent pen. Then he got started on the anecdote.

  Before his career in obs and gynae, Mr Lockhart worked as a GP in South London for a short chunk of the seventies. He celebrated getting a permanent job in general practice by buying himself a bright blue MGB convertible. The car was his pride and joy: he talked about it constantly to patients, friends and colleagues; waxed and polished it every weekend; only just stopped short of having a photo of it on his desk. And then one day it was over, as happens with all one-sided love affairs, when he finished surgery and clocked that the bright blue MGB convertible was missing from the surgery car park. He called the police, who did all they could, but ultimately failed to find the car. Lockhart’s topic of conversation with patients, friends and colleagues now switched to the wretched state of the world – how could someone steal his beautiful car?

  One day he was telling his tale of woe to a patient, who turned out to be a high-ranking member of what amounted to a local family of gangsters and, thanks to that bizarre moral code criminals seem to hold dear, was disgusted by this. What kind of lowlife would steal a doctor’s car? Absolutely unacceptable. He said he was sure he’d be able to identify the felon and persuade them to return the car, though Mr L of course said there was absolutely no need – the same way you would claim there was ‘absolutely no need’ for someone to buy you an all-expenses-paid trip to the Seychelles. In other words, ‘go on then’.

  Later that week, Lockhart arrived at work to find a bright blue MGB convertible in the car park, its keys on the dashboard. His overwhelming relief turned to more mixed emotions at the realization that the car had a completely different number plate and interior.

  Saturday, 15 November 2008

  An email from Mme Mathieu telling me, with great regret, she’s refunding the rest of the term’s fee for my Conversational French class because I’ve now missed so many lessons it’s pointless coming back. Email correspondence with Mme Mathieu is usually conducted entirely in French to fully immerse us in the language. This is the first email I’ve had from her in English; she’s clearly not confident I’d understand otherwise, which really rubs sel into whatever the French for ‘wound’ is.

  Monday, 17 November 2008

  Superstition dictates you can’t ever describe a shift as ‘quiet’. Much like you don’t say ‘good luck’ to an actor or ‘go fuck yourself’ to Mike Tyson. Say the Q word to a doctor and you’re all but performing an incantation, summoning the sickest patients in the world to your hospital. I turn up for a locum night shift on a private obstetric unit and the registrar lets me know it should be ‘very quiet tonight’. Before I have time to flick water at her and rattle off a few ‘THE POWER OF CHRIST COMPELS YOU!’s she tells me a high-ranking royal from a Gulf state has just delivered a baby on labour ward, which goes some way to explaining the Oscars-level security everywhere and all the suede Ferraris outside.

  As far as I’m concerned, roping off three tables in All Bar One for a twenty-first birthday is ‘a bit swanky’, but our esteemed guests have not only booked out the entire maternity unit so there’s not a single other patient around, but their consultant will be staying overnight as well, just in case. It was fair to say the shift was quiet.

  Tuesday, 18 November 2008

  Ron phoned me for some medical advice this evening. His dad has been losing a lot of weight and having mid-chest discomfort and increasing difficulty in swallowing. When he went to his local surgery about it this morning, the GP thought he was looking a little yellow around the gills and referred him to be seen by gastro within the week. What did I think was going on?

  If I was being asked on an exam paper, I’d have said it was metastatic oesophageal cancer with a survival rate of zero per cent
. If I was being asked by a patient I’d have said it was very worrying and we’d want to investigate extremely urgently to rule out the possibility of cancer.

  But if I’m asked by someone close to me? I said it sounded like his GP was doing everything right (true), and that it still could be nothing (definitely untrue – there was no plausible version of events where this was anything other than a very bad something). I desperately wanted it to be OK – for Ron and for his dad, who I’ve known since I was eleven – so I lied. You never lie to your patients to give them false hope, but there I was doing exactly that, reassuring my mate that everything would be fine.

  We’re constantly reminded by the GMC not to be doctor to friends or family, but I’ve always just ignored that and provided them an on-call private service. Because my job makes me such a useless friend in so many ways, I guess I feel like I have to offer something to justify my name on their Christmas card list. And this is basically why we’re taught not to.

  Thursday, 20 November 2008

  In no other job would you be expected to wear shoes from a communal supply on a ‘first come, first served’ basis. It’s like being at a Megabowl where people constantly get splashed with amniotic fluid, blood and placental tissue, and everyone’s too lazy to clean them afterwards.

  If you want your own personal white leather hospital clogs they cost around £80, so it’s previously only consultants who’ve splurged on them, gliding around the hospital like they’ve got two giant paracetamols on their feet. But now there’s a new breed of shoes called Crocs – they come in bright colours, do the same job and cost less than twenty quid. They have the added advantage of having holes in them, so you can padlock your pair together and no other bastard will get their hands or verrucas on them.

  Today a notice has appeared in the changing rooms: ‘Staff must under no circumstances wear Crocs footwear as the holes do not provide adequate protection from falling sharps.’ A frustrated personal stylist has added underneath, ‘And they make you look like a douche’.*

  * Presumably the same wag who changed the sign that says ‘Warning! Thieves are operating in this department!’ to ‘Warning! Surgeons are operating in this department!’

  Saturday, 22 November 2008

  Called to A&E to review a nineteen-year-old girl with heavy vaginal bleeding – same old, same old. What I’m in fact faced with is a nineteen-year-old girl who has taken kitchen scissors and performed her own labial reduction surgery. She valiantly managed to chop three-quarters of the way down her left labium minus before she called a) it a day, and b) an ambulance. It was an absolute mess down there, and bleeding heavily. I checked with my senior registrar that I wouldn’t inadvertently be performing female genital mutilation and go to prison if I cut off the loose end and over-sewed the bleeding edge. All fine, and I tidied it up. In honesty, she didn’t do much of a worse job than a lot of labiaplasties I’ve seen.

  I booked her into gynae outpatients for a few weeks’ time and we had a bit of a chat, emergency now out of the way. She told me she ‘didn’t think it would bleed’, to which I didn’t have anything to helpfully reply, and that she ‘just wanted to look normal’. I reassured her there was absolutely nothing wrong with her labia; they really, honestly, did look normal. ‘Not like in porn though,’ she said.

  There’s been a lot of media noise about the damaging effects of porn and glossy magazines on body image, but this is the first time I’ve seen it first-hand – it’s horrifying and depressing in equal parts. How long until we’re seeing girls stapling their vaginas tighter?*

  * The answer, as it turns out, was a year. A colleague saw a patient who’d superglued the introitus of her vagina because her boyfriend had been pressuring her to.

  Wednesday, 10 December 2008

  This week the hospital is running a diary card exercise.* I presume that in normal jobs they monitor employees because staff are working fewer hours than they’re paid for.

  Consultants never previously spotted on a ward are seen writing discharge summaries for patients, working a few hours in labour ward triage, reviewing patients in A&E – to maximize the chance of the juniors leaving on time. This will continue until the nanosecond the diary card exercise ends, of course, but for now I’m enjoying the rewards. It’s my third consecutive shift leaving on time, prompting H to sit me down and ask if I’ve been sacked.

  To ensure the illusion of accuracy, clerical staff from hospital management shadow a few doctors at random during their shifts. I was joined by one on a night shift – or at least until 10.30 p.m. when she went home, unironically announcing she was exhausted.

  * During a diary card exercise, every doctor has to record their exact hours worked. But because the hospital can’t (or don’t want to) pay us for the time we actually work, they render the process completely meaningless. Either they lean on us to lie in the diary cards and just record our contracted hours or they throw dozens of consultants onto the wards to temporarily ease the burden on the juniors.

  Monday, 29 December 2008

  Seeing a patient in gynae clinic whose GP recently started her on HRT patches and now has some PV bleeding. I ask her how long she’s been on the HRT and she lifts up her blouse and counts the patches. ‘Six . . . seven . . . eight weeks.’ Her GP hadn’t explained that she has to take the old ones off.

  Saturday, 10 January 2009

  Percy and Marietta’s wedding today felt like a huge triumph against the odds. Not one, but two doctors able to get their big day off work. And the whole day too, not like my former colleague Amelia, who could only wangle the afternoon of her wedding day off, and ended up conducting her morning clinic in full hair and makeup to make the timings work.

  The main miracle is they’ve managed to last this long together, despite a system seemingly designed to ruin their relationship. Percy and Marietta got their training posts in different deaneries, meaning the closest hospitals they could possibly work at over the course of five years were 120 miles apart. Rather than live together somewhere mutually inconvenient, Percy moved out to live in awful hospital accommodation and pop back home when the rota allowed, which it generally didn’t.

  In his speech, the best man, Rufus, a surgical trainee, compared their set-up to having a partner who works on the International Space Station. It was a brilliant speech, made all the more poignant because Rufus had to deliver it between the starter and main course. As soon as the pan-seared chicken livers were wolfed down, he had to dash off for a night shift.

  Monday, 12 January 2009

  Asked to review a patient in labour ward triage and repeat a PV as the midwife is uncertain of her findings. Her findings were of cephalic presentation with cervix 1 cm dilated. My findings are of breech presentation, cervix 6 cm dilated. I explain to mum that baby is bottom-down and the safest thing to do is to deliver by caesarean section. I don’t explain to mum which part of the baby the midwife has just stuck her finger in to 1 cm dilatation.

  Thursday, 22 January 2009

  I accidentally dropped the on-call bleep into the labour ward macerator this evening, sending it off to a crunchy death. A feeling very similar to pissing your jeans – that wonderful warm sensation of enormous relief, followed almost immediately with, ‘Fuck, what do I do now?!’

  Thursday, 29 January 2009

  Waited about a minute before making the uterine incision at caesarean until Heart FM had moved on to the next song. As appropriate as Cutting Crew may be for a surgeon, I refuse to deliver a baby to the refrain of ‘I just died in your arms tonight’.

  Friday, 30 January 2009

  Patient DT is twenty-five years old and has attended colposcopy clinic* for her first smear test. And her second smear test: she has complete uterus didelphys – two vaginas, two cervices, two uteri. I’ve never seen this before. I perform both smears and spend a minute or two working out how the fuck to label the slides and forms, as the NHS cervical screening programme isn’t really equipped for this admittedly rare scenario.

 
She’s not seen a gynaecologist since she was a teenager so has a bunch of questions for me. I admit I’ve never come across a case like hers before, but answer the questions as best I can. She’s mostly worried about future pregnancies.† I ask if she’d mind some questions in return. Potentially inappropriate, but we had a good rapport, and I’ll probably never get the opportunity to chat to someone with the condition again.

  Here’s what I learned. She used to mention it to guys before they had sex, which tended to freak them out, so now she doesn’t mention it at all. They apparently never notice in any case, which is hardly surprising – most guys’ knowledge of female genital anatomy is sketchy at best. Aside from the old ‘finding the clitoris’ cliché, many don’t seem to realize girls have a separate hole for peeing – they just think it’s one great multi-functioning service tunnel. More than once I’ve catheterized a woman during labour only for her partner to ask if that isn’t going to stop the baby from coming out.

  The patient tells me she prefers having sex with her left vagina, as it’s bigger (as I’d noted during examination – the right needed a smaller speculum), although she says it’s nice to have an option for ‘different sizes of guys’. I suggest that if she forgets which way round it is, the mnemonic ‘righty tighty, lefty loosey’ would apply – though in truth she’s probably very unlikely to forget which way round her vaginas are.

  I recount my tale to H after work. ‘So it’s like one of those metal pencil sharpeners at school with two sizes of hole?’

  * Colposcopy is a fancier way of doing smear tests – having a look at the neck of the womb for pre-cancer cells.

  † She’s likely to be able to get pregnant, but there’s increased chance of late miscarriage, premature birth, growth restriction and breech presentation, and she’s much more likely to be delivered by caesarean.