by Adam Kay
† A couple of years later, I encountered an example of condom failure where the guy thought that because a condom was coated with spermicide, and he didn’t really like the feeling of them, he could roll it on to coat his cock with spermicide, then take it off before sex.
Tuesday, 20 October 2009
We’re one registrar down in antenatal clinic, so I’m sailing this shitshow alone. I saw thirty patients in morning clinic, which finished at 3 p.m., two hours after my afternoon clinic was meant to have started.
All the patients I see are pissed off, and rightly so – they’ve been sitting in a waiting room for four hours, crotchety as a pen of wet hens. Safe to say my sincere apologies and not-my-faults don’t count for much while they grunt their way through their appointments. I strongly suspect if I was a pilot and my co-pilot didn’t turn up, the airline might find a better solution than ‘plough ahead and see what happens’.
Seven p.m. and two patients from the finish line I have to make an urgent psychiatric referral for someone who’s had a relapse of severe anorexia nervosa at thirty weeks. And she’s eaten more than I have today.
Wednesday, 28 October 2009
I need to admit a woman for pelvic inflammatory disease, to receive intravenous antibiotics. Unfortunately, she doesn’t want to receive any because she thinks I’m in the pocket of the pharmaceutical industry, so we’ve reached a bit of a stalemate. We talk through her concerns. It turns out this is a very recent worry, having read something about it on Facebook yesterday.
Yet another mark against technology as far as I’m concerned. The trust have finally acknowledged we’re in the twenty-first century and digitized our radiology system, doing away with all light boxes and physical printed X-rays. Instead we can now access them from any computer in the hospital. Unfortunately, the system has been broken since they installed it, thereby putting our practice back to the nineteenth century, before the introduction of X-rays.
Patients frequently attend clinic with reams of paper they’ve googled, printed off and highlighted, and it’s pretty tedious spending an extra ten minutes per patient explaining why a blogger in Copenhagen who uses a pink hearts Wordpress theme might not be a reliable source. Then again, if it wasn’t for Google I wouldn’t be able to send patients off for a urine sample while I look things up in a panic.
Today technology is serving up conspiracy theories. The patient asks me to prove I’m not being bribed by drug companies. I point out that the antibiotics I want to put her on cost a matter of pennies, and that drug companies would probably be furious with me for not choosing something more expensive. She doesn’t waver. I point out that the antibiotics I’ve prescribed are generic* rather than pushing one company’s product. Still unmoved. I point out that I drive a five-year-old Peugeot 206, so I’m probably as far out of anyone’s pocket as is possible. ‘Fine,’ she says and agrees to the antibiotics.
* Almost any drug you get at the chemist comes in both branded and cheaper generic forms. Panadol is a brand name for the generic drug paracetamol, Amoxil is a brand name for amoxicillin.
Wednesday, 4 November 2009
Patient TH is an accountant in her mid-thirties, who has been diagnosed with an ectopic pregnancy. She is a candidate for medical management using methotrexate,* and is keen to do so and avoid surgery. I consent her for receiving the drug, and talk through the follow-up procedure. I explain the possible side effects and the various ‘dos and don’ts’ while on treatment, emphasizing that she must use effective contraception for the next three months and abstain from sex altogether for the first month after treatment. She pauses to consider this, before asking, ‘How about anal?’†
* Certain patients with ectopic pregnancies can be managed with a drug called methotrexate, if they’re medically well and the ectopic is small. It’s a pretty nuclear drug which attacks rapidly dividing cells, meaning it’s effective at dissolving the ectopic pregnancy and can also be used in chemotherapy.
† If you’re interested, the answer is ‘yes, even anal’. There’s still a risk of the ectopic pregnancy rupturing, so we try to avoid any prangs in that neck of the woods.
Wednesday, 18 November 2009
Visiting Ron’s dad in hospital. He looks terrible, jaundiced skin stretched tight over jutting bone. A roadmap of blood vessels is visible across his face where his body has burnt away every single fat cell, throwing all its energy at fighting a cancer it has no chance against. ‘I wish people didn’t have to see me like this,’ he says. ‘We’ll be spending a fortune on the undertakers making me look nice afterwards – can’t you just wait a few more months?’
He’s in hospital for an oesophageal stent insertion so he can continue to eat and drink, to make his final chapter as comfortable as possible. The retired engineer in him is fascinated by the mechanism of the stent, a self-expanding metallic mesh, strong enough to push back the tumour and open up his gullet. ‘Wouldn’t have been possible twenty years ago,’ he says, and we talk about being lucky to live in this current blink of civilization’s eye. ‘Do you think they’ll be able to cure cancer twenty years from now?’ he asks. I can’t work out whether saying yes or no would be more comforting. I deflect with, ‘I only know about vaginas, pal,’ and he laughs.
Next question. ‘Why do we always say that people lost their battle with cancer, and never that cancer won its battle against them?’ He keeps making jokes – to be fair, he’s done it the entire time I’ve known him. I find it uncomfortable for the first few minutes of my visit, but I’m soon genuinely enjoying a morning I’d been dreading. It’s a kind and clever move – it doesn’t just make it easier for his friends and family when they visit, it also means we’ll remember him as he always was, diminished physically maybe, but not in personality.
Thursday, 10 December 2009
A poignant ventouse delivery – it’s a mum I saw in infertility clinic at the start of this job. I feel like holding the baby aloft like Simba and blasting out my best ‘Circle of Life’.
While I’m patching her up, I ask how her fertility treatment went – turns out she got pregnant without any treatment the week after our appointment. Still, I’m taking it.
Thursday, 17 December 2009
Tragically, domestic abuse in pregnancy is still responsible for the deaths of mothers and babies every year in this country. Every obstetrician has a duty to look out for it. This is often difficult as controlling husbands are likely to attend clinics with their wives, denying them an opportunity to speak up. Our hospital has a system to help women admit to abuse – in the ladies’ toilet there is a sign that says ‘If you want to discuss any concerns about violence at home, put a red sticker on the front of your notes’, and there are sheets of red-dot stickers in every cubicle.
Today, for the first time in my career, a woman has dotted a few red stickers on the front of her notes. It’s a tricky situation as she’s attended clinic with her husband and two-year-old child. I try and fail to get the husband to leave the room. I call in the senior midwife and consultant and between us we get her alone.
As gently as we interrogate, it’s not doing any good; she’s clamming up – scared, confused. After ten minutes we establish that the red dots were the early artistic efforts of her two-year-old, who stuck them on the notes when they went to the toilet together.
8
Registrar – Post Four
During my career as a doctor, for every ‘would you mind having a look at this lump/rash/penis?’ I heard off-duty, there was always one ‘I don’t know how you do it’. I generally heard it from people who wouldn’t qualify for jury service, let alone from medical school, but it’s still a valid point. It’s a difficult job in terms of hours, energy and emotion; and from the outside a pretty unenviable one.
By the time I was six years deep into medicine, the shine had definitely rubbed off the surface. On more than one occasion my finger had hovered over the ‘fuck it’ button – days where things had gone wrong, patients had complained, rotas ha
d changed at the last minute – and my resolve wavered. Not quite enough to start circling the jobs page of the paper, but certainly enough to wonder if I might have any long-lost millionaire aunts on their way out.
But there were two things keeping me there. Firstly, I’d worked long and hard to get as far as I had. Secondly – and I realize it might sound a bit worthy – it’s a privilege to be allowed to play such an important role in people’s lives.
You may be an hour late home, but you’re an hour late home because you stopped a mother bleeding to death. You may have had forty women in an antenatal clinic designed for twenty, but that’s forty women relying on you for the health of their babies. Even in the parts of the job you hate – for me it was urogynaecology clinic, a bunch of nans with pelvic floors like quicksand and their uteri stalagtite-ing into their thermals – each decision you make can immeasurably improve someone’s quality of life. And then a patient sneezes, you have to get a mop and bucket, and you wish you’d plumped for a career in chartered accountancy.
You may curse the job and the hours, own voodoo effigies of the management and even carry a vial of ricin on you at all times in case you ever meet the health secretary, but on an individual basis you really care for all the patients.*
I must have been in this kind of upbeat mood in my fourth registrar posting when I accepted an invitation to represent medicine at my old school’s careers fair. It involved a morning sitting behind a table, while a bunch of gangly fifth-formers lumbered around and asked me questions about my job. Or as it turned out, mostly asked a bunch of other people questions about their more interesting and better-paid jobs. My table definitely looked the least appealing – everyone else had stacks of leaflets and bowls of pens, sweets and key rings. Deloitte were even handing out Krispy Kremes, which felt a bit like cheating. What should I have brought to entice people into a career in medicine? Toy stethoscopes? Amniotic fluid smoothies? Diaries with all your weekends, evenings and Christmases handily crossed out?
The students who did speak to me were clever, driven and erudite – I’m sure they would have all breezed into medical school if they chose to – and I found myself spending a lot of time discussing what’s bad as well as good about the job. Even though I felt protective of my profession, particularly with the other tables around, Christ knows we need people to go into it with both eyes open. So I told them the truth: the hours are terrible, the pay is terrible, the conditions are terrible; you’re underappreciated, unsupported, disrespected and frequently physically endangered. But there’s no better job in the world.
Infertility clinic: helping couples to fall pregnant after years of trying, who’ve all but given up hope – it’s difficult to explain how special that feels. It’s something I’d happily do in my own time and for free (which is handy as I frequently did – those clinics overran by hours). Labour ward: a true rollercoaster, by which I mean everyone generally ends up alive and well despite the fact it seems to be against the very laws of nature. You dart from room to room, delivering any baby who gets sick or gets stuck, making an indelible mark on the lives of these patients. A low-grade superhero – your utility belt containing a scalpel, some tongs and a wipe-clean hoover.
The careers on the other tables had their obvious draws – the principal one being a shit-ton of cash every month – but there’s no feeling like knowing you’ve saved a life. Not even that, half the time; just knowing you’ve made a difference is enough. You go home – however tired, late and blood-splattered – with a spring in your step that’s hard to describe, feeling like you have a useful part to play in the world. I said this little speech about thirty times, and by the end of the morning I felt like I’d been through rigorous couples therapy – talking all the problems out, realizing the spark was still there after all.
I felt uplifted as I left the school hall, actively looking forward to hitting labour ward on Monday. What an honour it is to do this job – even if it is significantly worse than the sum of its parts. I stole a Deloitte doughnut and headed home.†
And the next time someone asked me ‘Seriously, how do you do it?’ I truly knew what the answer was. Although the reply I generally gave was ‘I like operating on strangers’ vaginas’, which at least ended the conversation quickly.
* Except the ones who try and sue you.
† Full disclosure: I did also take a leaflet about their graduate entry scheme.
Friday, 5 February 2010
Doing an elective section for a woman who’d had three previous sections – her abdomen is absolutely rock-solid with adhesions. I call my senior registrar in to help, and demote the SHO to a spectator role. Scar tissue means that bowel is matted to bladder is matted to uterus is matted to muscle is matted to God-knows-what. It’s like ten pairs of headphones have become tangled together, and then the whole thing has been encased in concrete.
The senior reg tells me it will take as long as it takes – we just need to be slow and methodical. Better that it takes three hours than the patient needs her bowel repaired and spends an extra week in hospital. We assume the pace of an arthritic archaeological dig. Every time it gets a bit easier and I speed up, the SR puts his hand on mine and I slow right down again.
Eventually there’s nearly enough space to make the cut and deliver the baby – just one last loop of bowel to gently encourage away from the uterus. I’m in the process of peeling it off when the unmistakeable fetid stench of bowel contents fills the theatre. Shit. Literally. And we were so close.
The SR tells me to deliver the baby – he’ll pop out and bleep a bowel surgeon over to repair the damage.* My SHO interrupts sheepishly, ‘Sorry, guys – that was my bowel . . .’
* To test for a bowel perforation, it’s a remarkably similar method to locating a hole in the inner tube of a bike tyre. You fill the abdomen up with water and pump air through the patient’s anus until you can see where the bubbles are coming from.
Saturday, 6 February 2010
I meet Euan, a friend from university halls, and his wife, Milly, for lunch in town – they’re feeding me in return for picking my brains about fertility issues. The mains arrive and I switch from reminiscence mode to doctor mode. ‘So. How long have you been trying then?’
‘Seven months and two weeks,’ replies Milly robotically, like a cash machine dispensing a tenner. She’s weirdly precise.
In fact, weird and precise would prove to be her watchwords, as she then dips into a tote bag to produce a folder, which she passes to me, stony-faced. I am clearly being granted sight of a document of colossal importance. I flick through page after page of spreadsheets; it takes me a moment to absorb the sheer horror of her magnum opus. This is a database of every time they’ve had sex since coming off contraception, alongside the dates of Milly’s cycle and, distressingly, the length of the session and who was on top. Quite why this was documented in such detail I have no idea, unless it was a deliberate attempt to suppress my appetite and keep the lunch bill down.
I’m totally distracted for the rest of the meal, unable to shake thoughts of my ex-flatmate’s sexual positions and durations, and him clambering on and off, or out from under, with the regimented duty of a workhorse. I manage to collect myself long enough to give them some half-decent advice: giving up coffee and alcohol, the blood tests they should get from their GP, the point where they need referral to infertility clinic.
‘Is it worth keeping the diary going?’ asks Milly.
‘Oh, definitely,’ I say – partly so they don’t think they’ve needlessly shown me a sex almanac and partly to give some poor infertility registrar a good giggle in a few months’ time.
Tuesday, 9 February 2010
Today, as I was making a perineum look slightly more like a perineum after a forceps extraction, the midwife asks mum if she’s happy for her baby to have a Vitamin K injection. The patient treats us to some tabloid newspaper sensationalist scare-story quackery – except it appears this woman may have been holding her paper upside down.
‘Nah,’ the mum says. ‘I’m not taking any chances with my baby’s health.’
Sunday, 14 February 2010
First Valentine’s Day spent with H in four years. I suggest that, Valentine-wise, going out with a doctor is like having your birthday on the 29th of February.
A lovely Thai dinner at the Blue Elephant restaurant. At the end of the meal, the waiter brings over a pair of heart-shaped sweets in a beautifully carved wooden box. I eat mine whole. Turns out it was actually a candle.
Tuesday, 16 February 2010
Husband and wife are both in tears at the news that baby will need to come out of the sunroof for failure to progress in labour. The main sadness seems to be the husband’s slightly odd obsession with being the first person to touch the baby. There isn’t much time to muse upon why he might want to do this – perhaps he wants to break an enchanted spell or has superpowers he needs to transfer to his offspring – but he is really most insistent. Isn’t there a way he can still be the person who touches her first? If he lifts her out at the end of the caesarean maybe?
