by Adam Kay
Monday, 24 May 2010
I never volunteer my opinions on home births, but if, as today, a patient specifically asks me what I think of them, what I’d have if it were me, then I’ll be honest. It’s a five-minute speech, as follows: I tell them I don’t doubt for a second that a home delivery that goes to plan must be a hundred times more calm, relaxing and pleasant than a hospital birth. (Though I’m not sure I could ever personally relax knowing that at any moment a blood and amniotic fluid emulsion might slosh onto the sofa. How would you go about getting that out?)
I then tell them I respect patient choice and that it’s crucial they feel absolute ownership of their care. I tell them I get worried by the increasing promotion of ‘natural’ birth, and that demedicalization of pregnancy isn’t necessarily a good thing – we should be proud of medical advances that objectively save lives, not scared of them.
I say I’ve seen a number of near misses, including one where we were seconds away from losing a child who’d been transferred to the labour ward when a home birth had gone pear-shaped. I also describe hospital deliveries I’ve seen in low-risk* mothers where rare and unpredictable events meant they or their baby would certainly have died outside of a hospital environment.
I promote midwife-based units, where women can have magical, wonderful births in more controlled environments. Crystals, beanbags, someone singing Radiohead songs backwards in Swedish – whatever floats your boat, just as long as you’re a few hundred yards from a labour ward and their team of shit–fan separation specialists.
I acknowledge that when it comes to home births I only see the disasters and never the successes, which some people describe as a fatal flaw in my argument. Presumably they also have issues with firemen who advise the use of seatbelts, because they only see the drivers they angle-grind out of pile-ups, not the majority of safe car journeys. I will put my hand on my heart and tell the patient I implore anyone close to me to think twice about having a home delivery.
Unfortunately, today’s clinic is running massively late, and I’ve got a dinner date, so I don’t have time for all this. Instead, I give the abbreviated version: ‘Home delivery is for pizzas.’
* On booking into antenatal clinic, patients are categorized as either high or low risk, and low-risk mothers are eligible for home births. People tend to forget that ‘low risk’ doesn’t mean ‘no risk’.
Wednesday, 2 June 2010
Teaching medical students this morning – they’re keen to brush up on their X-ray reporting skills. I grab a couple of films from the trolley and shove one up on the light box. It’s a normal chest X-ray of a patient, taken pre-operatively. The first student steps up to present.
‘This is a PA chest radiograph taken yesterday of a sixty-four-year-old female patient with name NW and date of birth 03/01/46. There is adequate inspiration and the film is well penetrated and not rotated.’ He’s good.
‘The trachea is central, the mediastinum not displaced and the cardiac contours are normal. The obvious abnormality is a curvilinear mass in the superior lobe of the right lung, occupying . . .’
Hang on. Abnormality? Where the hell did that come from? Holy fuck. I reviewed this earlier and missed a tumour – I’ve sent the patient off to surgery and her certain death. I push past the student to get a better look at the cancer. Then I reposition the X-ray slightly and the mass moves. It was a ‘Give Blood’ sticker on the light box.*
*My friend Percy was working as an orthopaedic SHO when there was a trauma call to A&E – a motorcyclist had flown off his bike and broken all sorts of bones. The chest X-ray (routinely performed to check lungs haven’t been punctured), Percy was proud to announce, showed Varicella Pneumonia – a rare and dangerous complication of chicken pox with a characteristic X-ray appearance. The patient was clearly septic with this pneumonia, which caused him to lose control and fly off his bike. Or, as it eventually turned out, his lungs were fine – but loads of gravel had gone up the back of his jacket and shown up on the X-ray.
Saturday, 5 June 2010
My life is starting to feel like an episode of Quantum Leap. I’ll suddenly wake up and not know where I am or what I have to do. Today, I startle awake to a loud knocking sound – I’m sitting in my car asleep at a set of lights and an old boy is rapping on the window with the handle of his umbrella, asking if I’m OK.
It’s the second unexpected power nap of the night shift, after a scrub nurse tapped me on the shoulder while I was sat fast asleep on a theatre stool to tell me the patient was just being wheeled in for her marsupialization.* We’re repeatedly reminded not to use empty patient side rooms to catch any sleep overnight – the management maintains we’re paid to work full shifts. I want to ask the management if they’ve heard of that big ball of fire in the sky that makes it slightly harder to sleep during the day than at night? Or how easy they think it is to suddenly switch from working during the day and sleeping at night, to the exact opposite within twenty-four hours? But most of all I want to ask: if they or their wife needed an emergency caesarean section at 7 a.m., would they rather the registrar doing it had caught forty minutes’ sleep when things were quiet, or had been forced to stay awake every second of the shift?
It’s a surreal feeling being this tired – almost like being in a computer game. You’re there but you’re not there. I suspect my reaction times are currently the same as when I’m about three pints deep. And yet if I turned up at work pissed they’d probably be unimpressed – it’s clearly important my senses are only dulled through exhaustion.
I left work at 9.30 a.m. – it took me an hour to write up the notes for my last caesarean because I was really struggling to find the words, like I was trying to bodge the sentences together in Spanish for my GCSE. Do the courts take this into consideration when you nod off and mow down an entire family on the way home?
* Marsupialization is the treatment for a Bartholin’s abscess – when the glands that provide vaginal lubrication become infected. You create a pouch to help the abscess drain – hence marsupialization, like a genital kangaroo.
Friday, 11 June 2010
I tell a woman in antenatal clinic that she has to give up smoking. She shoots me a look that makes me wonder if I’ve accidentally just said, ‘I want to fuck your cat,’ or ‘They’re closing Lidl’. She refuses to entertain the idea of a smoking cessation class. I explain how bad smoking is for her baby, but she doesn’t particularly seem to care – she tells me all her friends smoked through pregnancy and their kids are fine.
I’m tired and just want to go home. I look at the clock: it’s half six, clinic was meant to end an hour ago and she’s far from the last patient on my list. I snap.
‘If you don’t stop smoking when you’re pregnant with a child then nothing on earth will stop you smoking, and you’ll die of a smoking-related illness.’ As I’m saying this I can hear it being repeated back to me slowly by a lawyer – I immediately apologize. But strangely, it seems to have worked – she looks at me like it’s the first time she’s ever truly listened to anyone, like she’s about to stand on the chair and exclaim, ‘O Captain! My Captain!’ She doesn’t, as luck would have it, because the chair doesn’t look like it could take it, but she does ask me about those smoking cessation classes. Good to know that death threats are effective on my patients.
On her way out she jokes, ‘Maybe I’ll start heroin instead!’ I laugh, and don’t mention that yes, that would genuinely be safer for her unborn child.
Monday, 14 June 2010
Prof Carrow is the consultant on call for labour ward today, which is about as much use as having a cardboard cutout of Cher on call for labour ward. In fact, Cardboard Cher might at least raise morale a bit.
You don’t see Prof Carrow during the day, you don’t phone him at night – he’s far too important for all that nonsense. When he appears on the ward this evening I can only assume that he’s got lost or one of his first-degree relatives is currently giving birth.
It all falls into p
lace as a documentary film crew show up behind him, cameras rolling.* ‘Talk me through the labour ward board,’ Carrow says to me, which I do. He nods along for the cameras. ‘Sounds like you’ve got it all under control, Adam. But if you’ve got any problems at all during the night, just call me.’ The crew have what they want and stop recording. Prof doesn’t miss a beat before saying, ‘Obviously, don’t.’
* In London you’re never more than six feet from a rat – and in a big hospital you’re never more than six feet from a documentary film crew.
Tuesday, 15 June 2010
I’ve spent a lot of time with patient VF, as I’ve been performing FBSes* on her baby every hour. She and her husband have been having a blazing argument for the last four. It started with something about his parents, we’ve heard all about some friend’s wedding where she was flirting with Chris again, and now we’re on to money. If I was at their dinner party I’d have secreted my uneaten pudding into a napkin, made my excuses and headed home ages ago, but I don’t really have any choice but to eavesdrop. It’s a thorough demonstration of the threadbare state of their relationship – I feel like a marriage counsellor who’s been rendered completely mute.
In truth, they’re behaving equally despicably, but given she’s currently in labour – a famously non-fun process – I have to award him 100 per cent of the bastard points.
At one stage he goes out to take a phone call and the midwife quite rightly checks with VF that he’s not been hitting her. She assures the midwife this isn’t the case. He returns, the arguments continue, then escalate. He’s puce-faced and yelling at her – we all ask him to either calm down or step out of the room. He screams at her, ‘I never wanted this fucking baby anyway,’ and storms out, never to reappear in the hospital. Jesus.
* Fetal Blood Sampling (FBS) is the most accurate way of checking baby’s well-being – you lie mum on her side, stick a short length of guttering in her vagina and make a cut on the top of baby’s head using a knife on a long stick. There’s no pretending it’s any more advanced than this. You then collect a drop of blood in a small capillary tube, and the midwife runs off to drop it, lose it, find that the machine is broken, or occasionally report back with the pH of the baby’s blood. For some reason they choose not to mention this fairly common procedure in antenatal classes.
Friday, 18 June 2010
Patient RB presented to A&E with an ambulance crew and two police officers. And also, of note, a foot of metal pole protruding from her. She was being chased on foot by the police for some reason or other, and her escape plan involved climbing over some railings into a park. The escape plan unfortunately failed just as she was getting over the railings, when she slipped and one of the metal spikes slid up her vagina and penetrated through the front of her abdomen.
She’d had the presence of mind to get off her face on cocaine earlier in the evening, which anaesthetized her sufficiently until the Fire Brigade arrived on the scene and were able to cut off the railing just below vagina level (while presumably saying ‘holy shit’ quite a lot). She arrived here haemodynamically stable and remarkably well, all things considered, so we arranged an urgent CT to delineate precisely which cuts of meat were skewered on this particular kebab. Miraculously, she’d avoided damage to her bladder and major blood vessels, so it was just a case of taking her to theatre and sewing up the entry and exit wounds.
We reviewed her after surgery – sober, sore, embarrassed, and with a police chaperone, as she was still under arrest. We told her that all looked well and gave her a post-operative management plan. She asked if she could keep the spike as a souvenir, and I said I couldn’t see any reason why not. The policeman came up with a convincing one – it’s really not a good idea to give an arrested criminal a weapon capable of piercing an abdomen.
Tuesday, 22 June 2010
What to do when you’re managing an emergency and there’s another emergency? I’m on labour ward when the buzzer goes off – mum’s pushing and there’s a horrendous-looking trace, baby needs to be urgently lifted out with forceps. I do the necessary and baby comes out quickly, but it’s floppy. The paediatrician does her magic and the baby yelps to life. Placenta out and the patient is bleeding moderately, from a combination of the generous episiotomy* and a slightly boggy uterus. I start to do part two of the necessary when I hear another emergency buzzer. I’d better stay – this could quite easily escalate into a major PPH,† and in any case she’s already losing blood every moment I’m not sewing her up or calling out the name of the next drug for the midwife to inject. On the other hand, this other unknown emergency could be much worse – and my current patient is very unlikely to suffer permanent harm if I leave her in the hands of an experienced midwife.
It’s daytime, but who’s to say all my colleagues aren’t busy with patients, each assuming someone else will attend the emergency buzzer, which continues to sound. Or what if it’s the kind of emergency that needs all hands on deck? I consider sending the midwife to report back, but that minute might be critical for the other patient. I hand the midwife a large swab and tell her to press hard on the perineal wound until I get back, and give her instructions about the next couple of drugs to get into the patient if necessary. I sprint out. The light is flashing outside room three and I bound in, hoping I’ve made the right decision. Naturally, I haven’t.
A midwife is running a CPR drill. There’s a mannequin on the bed and a bunch of doctors and nurses calling out what they’d do were this a real emergency. Which it isn’t. Unlike the one I’ve just left. ‘Right, the registrar is here,’ says the midwife to the SHO. ‘What would you like him to do?’ What I in fact do is walk up to the mannequin, push it off the bed and call the midwife a cretin, accusing her of deliberately sabotaging patient safety. Then I bolt back to the first room, where all is thankfully stable, and get my non-imaginary patient as good as new. (OK, not quite.)
I clearly hadn’t expressed my feelings adequately earlier, as the midwife supervisor takes me aside afterwards and asks me to apologize to the midwife in question for disrupting her simulation and upsetting her. My apology takes the shape of a clinical incident form, citing this simulation as a dangerous near miss. I’m sure I used to be nice before this job.
* An episiotomy is a cut made with scissors (I’d love to say they were special surgical scissors but they’re just normal scissors) into the perineum to prevent a tear that would be harder to repair or might go into the anus. Essentially, it’s a controlled explosion.
† PPH means postpartum haemorrhage to half of all doctors and primary pulmonary hypertension to the other half, due to a naming ambiguity.
Wednesday, 23 June 2010
An email reminds us of the crucial importance of skills drills training for all clinical staff. However, before any drill is called, it is now policy to check all rooms to ensure no staff are otherwise engaged in emergencies.
Monday, 5 July 2010
A rare bit of continuity of care today. I saw this patient a month or so back in Miss Burbage’s general gynae clinic, and it sounded very much like she had premature ovarian failure. Early menopause is rather beyond my scope, which I confessed to the patient, and excused myself while I left the room to speak to Miss Burbage for a management plan. She thought it was beyond her scope too, and it would be best to pop her into Mr Bryce’s specialist endocrinology clinic in the next available slot. The patient wasn’t too upset about the waste of her morning, knowing that she was getting to see the expert next time.
Today, however, I’m the registrar in Mr Bryce’s endocrinology clinic, and he’s off on holiday. Last time I saw the patient, I said I didn’t have the faintest idea about her condition, and now she’s sitting opposite me, having given up another afternoon to be here, expecting answers, needing help. Do I say I was just being modest last time? That I’ve been on a course since then? Do I put on an accent? Fake moustache?
I book her into clinic in a fortnight, when I know I’ll be on nights, to avoid the possibility of a h
at-trick.
Tuesday, 27 July 2010
Ron tried to dump me as a friend today – a proper, sombre, grown-up discussion. He doesn’t know why he bothers trying to keep in touch with me when it’s clear our lives have drifted apart massively since school.
I should at least vary up the excuses I give him. Do I really expect him to believe I couldn’t come to his engagement party or his stag do because of work? That I couldn’t make the wedding ceremony because of work, and almost missed the reception as well? That I missed his dad’s funeral and his daughter’s christening because of work? He knows my job’s full-on, but how hard can it be to swap shifts if it’s something you really want to do?
I put my hand on my heart and swear to Ron that I love him, he’s one of my best friends and I wouldn’t lie to him. I know I’ve been useless, but I’ve seen a lot more of him than almost anyone else I know – the job is just unimaginably busy. Non-medics can never appreciate quite how tough it is to be a doctor and the impact it has on real life. I totally lied about the christening, though – fuck that shit.
Monday, 2 August 2010
It’s the final shift of the job – a night shift, naturally. My new post starts an hour before this one ends, about ten miles away – but I’ll cross that bridge when I come to it, two hours late and bleary-eyed.
Technically this job ended at midnight, a fact that occurs to me on the stairwell at 12.10 a.m. when my swipe card refuses to let me back onto the ward and I realize it’s been automatically deactivated. I’m Cinderella in scrubs.
If you ask the hospital to adequately staff a department, provide an effective computer system or even supply enough chairs for clinic, you’ll get a shrug and a display of colossal incompetence. And yet when it comes to being able to get in and out of doors, they somehow take on the organizational skills of a cyborg librarian. If swipe cards suddenly start developing cancer, a cure will be found immediately.
