by Adam Kay
I endure a mere quarter of an hour of banging on doors and praying the crash bleep doesn’t go off before someone spots me and lets me back onto the ward.*
* The savvy obstetrician doesn’t carry his mobile phone in his scrubs. All it takes is one iPhone to drown in a tsunami of blood for you to learn your lesson; and I can assure you that no amount of soaking it in rice will revive it.
9
Senior Registrar
Medicine is the host who manages to keep you at their party hours after you first think about leaving. ‘Don’t go before we’ve cut the birthday cake . . . You must meet Steve before you head off . . . I think Julie lives over your way – she’s off home in a minute, why don’t you go together . . .’ Then before you know it you’ve missed the last train back and you’re crashing on the sofa.
Having gone to medical school you might as well finish and become a house officer, then you might as well become an SHO, then you might as well become a registrar, then you might as well become a senior registrar, and by then you’re practically a consultant. There almost certainly don’t need to be so many different grades; I strongly suspect it’s designed so that the next step is always just round the corner. It’s the £50 note you chase down the street, swept up by another gust of wind the millisecond before your hand makes contact. And it definitely works. One day I realized – as if blinking awake after a serious accident – that I was now in my thirties, still in a career I’d signed up for fourteen years earlier, based on the very flimsiest of reasons.
My ID card and salary now proudly said ‘senior registrar’ (although in fairness my salary also said ‘bank cashier’ or ‘reasonably experienced milkman’) and my next few postings would bridge the gap from junior doctor to consultant. And, in fact, life as a consultant looked pretty appealing. The pay goes up, the hours go down. Admin sessions, days off. No one forcing me to do urogynae clinics. My name in capital letters at the top of my parents’ will (probably followed by ‘he’s a consultant gynaecologist, you know’). And, best of all, stability: a job that I can stay in as long as I want, where I don’t have to pack my bags as soon as I’ve memorized the code on the changing-room door.
But first I had to get through my senior registrar posts – the storm before the calm. Yes, my registrar jobs had been manic and relentless, but this was a different kind of stress – now I was the highest-ranking person in the department out-of-hours. Knowing that when my bleep went off it was a problem that both the SHO and the registrar had failed to resolve. Knowing that if I couldn’t deal with it, a mother or a baby might die. Having a consultant at home ‘on call’ is just a formality: most emergencies will be over in a matter of minutes, before they can even change out of their dressing gown. I would now need to accept ultimate responsibility for the fails and fuck-ups of an SHO and registrar I may have never met before. While I’d often go unbleeped for an hour or two on a night shift, I preferred to prowl anxiously around labour ward, flitting from room to room asking ‘Is everything ok?’, suffering the occasional flashback to that registrar who told me as a student that obs and gynae was an easy specialty. Lying bastard.
So it wasn’t the biggest surprise in the world when I registered with a GP and the practice nurse recorded my blood pressure as 182/108 mmHg.* She wouldn’t accept my explanation that I was just off a night shift with two locums, still tightly wound from twelve hours on the wards, my mind jittering with a dozen medical equivalents of ‘Did I turn the gas off?’ Did the patient have that CT scan? Did I put in a second layer of stitches? Did I prescribe that methotrexate?
She booked me back in to see the GP the following week, and it was just as high. Again, I was straight back from work. I assured her I’d checked it myself in clinic and it was completely normal, but she wanted to be sure, just the same. In fairness to her, I was totally lying: I’d done no such thing. She arranged for me to have twenty-four-hour ambulatory monitoring.† Because days off work were in short supply, I wore it on an antenatal clinic day, making it practicable (I won’t have to go to theatre) plus theoretically low stress. I sat in clinic and explained to patients that I needed to start them on antihypertensive medication, despite the device strapped to my arm proudly displaying that my blood pressure was significantly higher than theirs.
Among all the predictably ‘hilarious’ remarks the patients made to me, one said something surprisingly astute. ‘It’s funny – you don’t think of doctors getting ill.’ It’s true, and I think it’s part of something bigger: patients don’t actually think of doctors as being human. It’s why they’re so quick to complain if we make a mistake or if we get cross. It’s why they’ll bite our heads off when we finally call them into our over-running clinic room at 7 p.m., not thinking that we also have homes we’d rather be at. But it’s the flip side of not wanting your doctor to be fallible, capable of getting your diagnosis wrong. They don’t want to think of medicine as a subject that anyone on the planet can learn, a career choice their mouth-breathing cousin could have made.
After an hour at home, my blood pressure returned to normal, so mercifully my arteries were still in decent nick. Plus it was interesting to be able to quantify in millimetres of mercury precisely how stressful it was to be a senior registrar.
* You’d want your blood pressure to be under 120/80 mmHg, aka millimetres of mercury. If you stuck a glass tube full of mercury into your heart, it’s the number of millimetres the pressure would push the level up – though these days we use a slightly less invasive method to measure it. The top number is the pressure when your heart is going ‘lub’, the bottom number is when it’s going ‘dub’.
† Ambulatory monitoring involves wandering round with a blood-pressure cuff on your arm for a day, which inflates every fifteen mins or so and records the data for the doctor. It’s particularly useful in ‘white coat hypertension’ when patients get nervous on visiting the doctor, so their BP rockets up whenever it’s measured. About a week before finals at medical school, my friend Antonin asked during a tutorial, ‘Why’s it called white goat hypertension?’ He’s a consultant haematologist now if you want to watch out for him.
Monday, 9 August 2010
A patient named their baby after me today. It was a planned caesarean for breech presentation, and after I delivered the baby I said, ‘Adam’s a good name’. The parents agreed, and job’s a good ’un.
I say ‘Adam’s a good name’ after every single baby I deliver, and this was the first time that anyone’s ever said yes. I’ve not even had a middle name before. But today this wrong was righted, and the squad of Adams I so richly deserve was launched in theatre two. (I’m not sure what I’ll do with this team once they’re assembled. Fight crime, maybe? Get them to cover my shifts?)
The SHO assisting me in the caesarean asked how many babies I’ve delivered. I estimated 1,200. He then looked up some population data and told me that on average 9 of every 1,200 babies born in the UK would be called Adam. I have genuinely put off eight sets of parents from naming their child after me.
Sunday, 15 August 2010
Summoned to a delivery room by one of the junior registrars – she’s struggling to lock a pair of forceps onto the baby’s head. We’ve had the occasional set of mismatched pairs sent to us recently – two left sides or slightly different models packed together after sterilization. On examination, the left blade is placed well on the side of baby’s head. The right blade, however, is wedged halfway up the patient’s rectum.
Mistake corrected and baby delivered safely. (By me – at this point I wouldn’t trust the registrar to deliver a limerick.)
‘Do we have to tell her?’ she asks conspiratorially, testing my ethical boundaries like I’m a builder and she’s hoping to avoid the VAT.
‘Of course not,’ I say. ‘You do.’
Monday, 23 August 2010
Week three of the job and I’m just about up to speed with the infertility* treatment eligibility criteria here. Today I saw a couple who’ve had an unsuccessful round
of IVF – which was unsurprising. Chances of success in their particular case were around 20 per cent for a single cycle. Where I worked a month ago, a walkable distance away, they’d have qualified for three cycles, which would have upped their odds to nearer 50 per cent. They ask me what private treatment would cost and I tell them – around four thousand pounds for a cycle. The look on their faces tells me I may as well have said four trillion pounds.†
People say it’s a choice to have kids, which is of course true. But no one argues that patients with recurrent miscarriages shouldn’t be allowed treatment until they have a baby – and the NHS rightly doesn’t limit their care. And how about the patient who had two ectopic pregnancies, leaving her with no fallopian tubes and no chance of getting pregnant without IVF? All we’re doing is allowing people to make a choice they would have otherwise had were it not for a medical condition. Or not, because their surname begins with the letter G. I’m exaggerating of course – that would be ridiculous. They’d only be denied it for sensible reasons, such as living one road outside of an arbitrary catchment area.
I suggest they take a bit of a break to think about their options and come to terms with their feelings. I float the possibilities of fostering or adoption. ‘It’s not the same though, is it?’ the husband says, and no, it’s probably not.
In the short time I’ve been working here I’ve told a lesbian couple they are eligible for treatment but a gay male couple wanting surrogacy that they’re not. I’ve told a woman she’s too old for treatment according to our criteria, even though she wasn’t too old when she was referred here a few months ago. (And wouldn’t have been too old a few streets away.) I’ve been cast in the role of a malevolent god.
Here there’s a BMI limit for receiving treatment – something I’ve never encountered before. I had to tell a patient she was three kilos too heavy to be referred for IVF and to see me again when she’d lost the weight. She burst into tears, so I accidentally recorded her weight on the form as a few kilos too light.‡ Last week I wrote a letter citing exceptional circumstances, requesting treatment be allowed for a woman who had a child from a previous relationship who died in infancy, which cruelly makes her ineligible for treatment here.
I leave clinic, passing a rack of leaflets that details all the different fertility treatment options that the NHS in this area makes it all but impossible to receive. We should be more honest and replace them all with one called, ‘Have you thought about getting a cat?’
* Infertility clinic got rebranded to ‘subfertility clinic’ during the course of my training to make it sound less negative, and then again to ‘fertility clinic’, which feels a bit ‘la la la this isn’t happening’ fingers-in-ears-y. Unless over in oncology they’re now running the ‘definitely not got breast cancer’ clinic?
† In most aspects of private medicine, you get a mild upgrade on the NHS, but no huge difference in actual care. You get seen a bit quicker, the receptionist’s got all her teeth and there’s a decent wine list for your inpatient stay – but ultimately you get the same treatment. When it comes to infertility medicine though, the private sector is leagues ahead – they will investigate and treat you until you have a baby (or an insolvency order). The NHS requires you to fit into quite a narrow demographic to qualify for any treatment, and it’s often not enough to achieve a positive result. I understand there’s a limited pot of money, but you don’t ever hear this said in other corners of medicine. ‘We don’t treat leukaemia – there’s a limited pot of money.’ ‘We only treat fractures on the right side of the body – there’s a limited pot of money.’
‡ Is this the ‘one weird weight-loss trick that doctors don’t want you to know about’ much vaunted by internet adverts?
Wednesday, 25 August 2010
An eighty-five-year-old, long-stay gynae oncology patient broke our hearts on yesterday’s ward round. She misses her late husband, her children have barely visited since she’s been in hospital and she can’t even have her usual whiskey nightcap in here. I decided to play Boy Scout, prescribed whiskey (50 ml nightly) on her drug chart and gave the house officer £20 to get a bottle from the supermarket to pass on to the nursing staff, so they can fulfil the prescription on their drug round.
This morning, the ward sister reports that the patient declined her drink because, and I quote: ‘Jack Daniel’s is fucking cat piss.’
Monday, 13 September 2010
A new midwife supervisor, Tracy, has started this week and seems absolutely lovely – calm, experienced and sensible. She is now the second midwife supervisor on the unit called Tracy, the current one being a flappy, angry nightmare. To avoid confusion, we have nicknamed them ‘Reassuring Trace’ and ‘Non-reassuring Trace’.
Friday, 24 September 2010
Moral maze. A Crackerjack bleep from theatre – it’s Friday, it’s five to five, it’s something enormously time-consuming. Today’s contestant is an emergency ectopic, and theatre would like me to pop up now. This is particularly annoying timing as it’s date night. In fact, it’s more than date night. It’s date night somewhere extremely expensive to apologize for half-a-dozen recently cancelled date nights and to paper over the widening fault lines in our relationship. It’s D-Date night. I should be fine if I leave by 6 p.m., I tell myself. At 5.45 it’s time to start operating. The evening registrar is stuck in A&E and can’t relieve me.
Best practice is to operate laparoscopically – about an hour’s work for me, it leaves the patient with a couple of tiny holes and she’ll be home tomorrow. Alternatively, I can make a quick incision in this twenty-five-year-old’s pristine abdomen and sentence her to a proper scar and a longer hospital stay – but get away on time and keep my relationship on track. Besides, maybe the patient likes hospital food? I hesitate for a moment more, then request the laparoscopy set.
Tuesday, 5 October 2010
On the phone to my friend Sophia, having a moan about the levels of exhaustion and demoralization in our hospitals. We’re both pretty fed up. She tells me she’s just got her private pilot’s licence and is planning to take a break from the NHS. ‘And work for an airline?’ I ask.
Actually, she’s going to charter an aircraft and fly it around twenty-four African countries, visiting remote areas where maternal morbidity is the highest and teaching the local midwives some life-saving techniques. She’ll also donate huge amounts of medical supplies and educational resources which she’s going to fundraise for before she sets off. Now I feel exhausted, demoralized and selfish.
Monday, 11 October 2010
A text out of the blue from Simon; no news has been good news for the last eighteen months so my heart rather sinks when I see his name pop up. He’s just asking for my address – he wants to send me a wedding invitation. I’m choked up that he’d think of me, and very much looking forward to intending to go, then pulling out at the last minute due to work.
Tuesday, 12 October 2010
The final patient of a comically busy antenatal clinic requests an elective caesarean section because of a previous traumatic vaginal delivery. This is a fairly common request – principally because there’s no such thing as a non-traumatic vaginal delivery. The SHO who saw her last did the sensible thing and requested the notes from the hospital where she had her last baby, and I skim through them to see if anything particularly traumatizing had happened.
She had a long labour, resulting in a forceps extraction, and needed repair in theatre afterwards for a cervical tear. That night, she had a gargantuan postpartum haemorrhage, which caused her to arrest. She was successfully resuscitated – clearly, given she’s sitting in clinic – and was taken back to theatre to resew her tear. This second attempt – almost unbelievably – went even worse and resulted in damage to her small bowel, and ultimately to a small bowel resection and stoma formation. Then a series of clinic letters from psychiatry, documenting her gradual recovery from PTSD caused by these events, and the collapse of her marriage. And now she’s back to do it again. The woman must b
e so hard you can skate on her; let her have what she wants.
I book her in for an elective section. It’s nice to have the bar set so low that almost anything we do will be a considerable upgrade on last time.
Thursday, 14 October 2010
I was slightly weirded out the first time a patient started texting during an internal examination, but now it seems reasonably common. Today, during a smear test, a patient FaceTimed her friend.
Sunday, 17 October 2010
I attend an emergency buzzer late at night – it’s a shoulder dystocia.*
It’s clearly a big baby, quadruple-chinned through how tightly its neck is being squeezed back against mum’s perineum – and it’s an experienced midwife, who I know will have already tried everything in the book. There’s no pretending to the patient this isn’t serious, but she’s a dream so far – remaining calm and going along with everything asked of her.
I drain the bladder with a catheter, put her legs in McRoberts’ position, apply suprapubic pressure. This is like no shoulder dystocia I’ve dealt with before. There’s no give at all; the baby isn’t budging. I ask the midwife supervisor to see if there are somehow any obstetric consultants in the building. I attempt Wood’s Screw manoeuvre: nothing. I attempt to deliver the posterior arm: impossible. I roll the patient onto all fours and try all the manoeuvres again in this position. I ask the midwife to get my consultant on the phone. It’s approaching five minutes of shoulder dystocia and something needs to happen urgently if the baby’s going to live.
As I see it, I have three options as last-ditch attempts. The first is Zavanelli’s manoeuvre – push the baby’s head back inside and perform a crash caesarean section. I’ve never seen it done but I’m confident I can manage it. I’m also fairly confident that by the time we get her delivered in theatre the baby will have died.
