by Adam Kay
Second option is to intentionally fracture baby’s clavicle to allow baby to deliver. I have never seen this done either, and have no real idea how to go about it – it’s a famously difficult procedure, even in much better hands than mine.
Third option is to perform a symphisiotomy, cutting the mother’s pubic bone to make the outlet bigger. Again, I’ve never seen it performed, but I’m sure I can do it easily, and that it will be the quickest way to get the baby out. I inform the consultant over the phone that this is what I’m going to do – she checks what I’ve tried so far and confirms my understanding of how to perform it. She’s driving in from home, but we both know that by the time she arrives everything will be over, one way or the other.
I feel as sick as I’ve ever felt in a clinical situation: I’m about to break a patient’s pelvis and it might already be too late for her baby. Before I take the scalpel to her I have one last attempt to deliver the baby’s posterior arm. All the various manoeuvres and shifts in position have somehow made something budge, and the arm delivers, followed by a very limp baby, who the midwife passes to the paediatricians. As we wait for the cry that may or may not come, I remember an old phrase in the textbooks that describes a successful shoulder dystocia delivery as ‘greater strength of muscle or some infernal juggle’ and totally get what the author was on about. The baby cries. Hallelujah. The midwife bursts into tears. We will have to wait and see if there’s an Erb’s,† but the paediatrician whispers in my ear that both arms seem to be behaving normally.
I see that I’ve given the mother a third-degree tear, which isn’t ideal, but is pretty minor collateral damage in the grand scheme of things. I ask the midwife to prepare her for theatre – that’ll give me twenty minutes to write up my delivery notes and grab a cup of coffee. My SHO comes in – can I quickly do a ventouse extraction in another room?
* Shoulder dystocia is one of the scariest experiences as an obstetrician – the baby’s head delivers, but the shoulders get stuck. All the time this is going on, baby’s brain isn’t getting any oxygen, so it’s a ticking time bomb of a matter of minutes before irreversible brain damage occurs. We all train regularly in how to manage this particular emergency. Embedded into our brainstems are all manner of mnemonics to help us through it, and all sorts of physical manoeuvres: exerting suprapubic pressure, McRoberts (hyper-flexing the legs), Wood’s Screw (rotating the baby by its shoulders), delivering the posterior arm.
† Erb’s palsy is nerve damage to the arm resulting from straining the neck in this kind of scenario.
Wednesday, 20 October 2010
Maybe it’s because his first language is Greek. Maybe he’s forgotten our previous discussion where I’d offered to help him with ultrasound technique. Maybe I should have phrased it as ‘determine fetal gender’. But judging by the SHO’s look of confusion and disgust and his hasty retreat down the corridor, what I shouldn’t have said was a cheery, ‘Would you like to watch me sex a baby?’
Thursday, 21 October 2010
I pick up notes for the next patient I’m seeing in gynae clinic. I recognize the name – flicking through the notes, I see a clinic letter I wrote to her GP back in March. I spot a horrifying typo in my sign-off, thanks to a missing ‘hesitate to’.
If you have any questions whatsoever, please do not contact me.
It worked, though. Not a peep.
Wednesday, 27 October 2010
I’m in occupational health for a follow-up HIV test after a needle-stick injury from a positive patient three months ago. She had an undetectable viral load but it’s still not ideal by any stretch, and I’ve had it constantly in the back of my mind since, like a bill from HMRC.
Making nervous small talk with the occupational health registrar as he takes my blood, I ask what happens to an obstetrician who’s HIV positive. ‘You wouldn’t be able to do clinical procedures, so no labour ward, theatre, on-calls – just clinics, I guess.’ I don’t say it, but that would really take the sting out of the diagnosis.*
* Since 2013, it’s been OK for an HIV-positive doctor with an undetectable viral load to operate, after a decade of lobbying that the risk to patients was negligible. My blood test was negative, in case you wondered whether the book was about to take a dark turn.
Sunday, 31 October 2010
At a friend’s Halloween party I spot someone I know from somewhere. School, I think.
I amble over to say hi. Blank face. Not school. University? Nope.
Where did you grow up? Have we worked together? Humiliatingly for me, but probably for his own sanity, he has to stop me and say that I’ve probably just seen him on TV before – he’s a presenter called Danny. Humiliatingly for him, I say the name maybe rings a bell, but I’m pretty sure that’s not it. His wife wanders over and I work it out – I delivered their baby by caesarean a year or so back.
Much hugging, hand-shaking and what-a-coincidence-ing. Danny jokes he’s glad it was a caesarean, because he doesn’t know how he’d feel about talking to a man who’s seen his wife’s vagina. I want to say that actually I’d have seen it when catheterizing her for the procedure, plus, if he really wants something to get his brain imploding, I’d have also seen its reverse side during the operation. I don’t say this, just in case he wasn’t joking and things get even more awkward.
Monday, 8 November 2010
The cherry on top of a record-breakingly hellish night shift (with a locum registrar who was of barely more than ornamental value) was a crash caesarean at 7.45 a.m., fifteen minutes from the supposed finish line. Caesarean, then another caesarean, then ventouse, then forceps, then caesarean, then I lost count, but a bunch more babies, and now a final caesarean. I’m absolutely exhausted, and would gladly have dragged my feet and handed it over to the morning shift were the trace not pre-terminal.*
I’ve not sat down for twelve hours, let alone rested my eyes, my dinner’s sitting uneaten in my locker and I’ve just called a midwife ‘Mum’ by accident. We run to theatre and I deliver the baby very quickly – it’s limp, but the paediatricians do their black magic and soon it’s making the right sort of noises. Cord gases confirm we made the right decision and I close up the patient on a vague high.
The paediatrician grabs me for a word after I leave theatre and tells me I’ve cut the baby’s cheek with my scalpel while making the uterine incision – it’s not bad, but just to let me know. I go straight to see the baby and parents. It’s not a deep cut, nor is it long – it didn’t need any skin closure and it surely won’t scar – but it was totally my fault. I apologize to the parents, who couldn’t seem to give less of a toss. They’re in love with their gorgeous (and only mildly mutilated) little girl, and they tell me they understand she had to be delivered in a bit of a rush – these things happen. I want to say that these things aren’t meant to happen, that they haven’t happened to me before, and they almost certainly wouldn’t have happened to me at the start of the shift.
I offer them a leaflet with the details of the PALS office – they don’t want it. A close shave for my GMC registration and an actual shave for the poor baby. A couple of centimetres higher and I’d have taken her eye out, a couple of millimetres deeper and I could have caused scarring and blood loss. Babies have even died from lacerations at caesarean. I document our discussion in the notes, fill in the clinical incident form, do everything demanded of me by the system that allowed this to happen in the first place. Before long I’ll get sat down by someone to be gently or not-so-gently chastised, and at no point will it occur to them that there might be a more fundamental problem here.†
* Pre-terminal means the baby is about to die if nothing is done.
† Almost a decade previously, I worked at the same hospital as a medical secretary during university holidays. We were obliged to take a twenty-minute break after every two hours of staring at a computer screen because of ‘health and safety’.
Thursday, 11 November 2010
I suspected the husband of the couple in infertility
clinic had a urinary tract infection so I gave him a specimen pot and sent him off to the toilet for a sample. He took the jar from me and peered at it for a few seconds before tottering off. I suppose it was my fault for not being specific enough, but he returned (admirably quickly) with the pot containing a few millilitres of semen. The miscommunication could have been worse, of course – he could’ve shat in it, bled into it or stuck a skewer into the ventricles of his brain to draw out a pot of cerebrospinal fluid. I do rather wonder whether the reason they’re struggling to conceive is that he’s urinating into his wife during sex.
Sunday, 14 November 2010
It’s Sunday lunchtime and patient RZ needs a caesarean section for failure to progress in labour. The patient is happy to have a section, but her husband doesn’t want me to perform it because I’m male. They are orthodox Muslim and have apparently been told they can have all female doctors. I say I don’t know who told them that but, although there are often women doctors available, we work on a rota and currently the entire team in obs and gynae is male, including the consultant on call at home.
‘So you’re honestly telling me that there are no female doctors in the hospital?’
‘No, sir, I’m telling you there are no female doctors in the hospital capable of performing a caesarean. I’m sure I could easily find your wife a female dermatologist.’
The patient is clearly much happier with the idea of me doing the section than her husband is, but she’s not really being allowed to speak up. We go through the motions, getting even further away from the result we need the more we dance around it. ‘When’s a woman doctor next here?’ When the shifts change in seven hours, which would be a very bad idea for your baby. ‘Can’t the midwife do it?’ No, and nor can the cleaner.
I call the consultant for some moral support. He suggests I drag up, and I suspect he’s only half joking. Back in the room, I ask, ‘Does the Koran not allow for male doctors to operate in the case of an emergency?’ Which, I remind them, this is. It’s a total bluff, but it seems the sort of thing a religious text might say. They ask me to give them five minutes, make some phone calls, then the husband comes to find me to say that they’re happy for me to deliver the baby. He says it in a way that implies I should be grateful. In fact, I am grateful, but only because my main concern was the safe appearance of his child, not his (or anyone else’s) God’s feelings on the matter. Plus I don’t have a Plan B and can’t begin to contemplate the unending quantity of paperwork that would otherwise haunt me forever.
The (male, naturally) anaesthetist pops in to get them sorted for theatre, and I wonder whether this will be a growing trend. Perhaps we should take a leaf from toilet cleaners and litter the floor with yellow ‘Male Obstetrician on Duty’ signs.
Before long we’re in theatre, and I’ve safely delivered their baby girl. Healthy mum, healthy baby – it’s all we ever aim for, and they should be glad everything worked out fine for them, when it doesn’t for so many families who come through these doors.
In the event, the husband is extremely thankful – he apologizes for wasting my time and adding to my stress, and tells me he’s grateful for all I’ve done. As with most husbands who kick off, he was probably just stressed by the situation, and I presume the added jeopardy of potential eternal damnation didn’t help either.
He’s going down to the shops, would I like anything? I half want to see his reaction if I ask for a BLT, a bottle of Smirnoff and some poppers.
Thursday, 18 November 2010
Was meant to be back home at 7 p.m. sharp but it’s 9.30 and I’ve only just come off labour ward. Feels appropriate that work commitments mean I have to reschedule collecting all my belongings from the flat. On the plus side, my depressing new bachelor pad is only ten minutes from the hospital.
Monday, 22 November 2010
A patient awaiting review in A&E for some minor abdominal pain has sunk lower and lower down my list of priorities throughout the afternoon as labour ward has become busier and busier. I’m in the middle of stabilizing a patient with severe pre-eclampsia when I’m bleeped by a furious A&E registrar.
‘If you don’t come to A&E right now this patient is going to breach the four-hour target.’*
‘OK. But if I do come right now my current patient is going to die.’ Mic drop.
There’s a good five seconds of radio silence where he clearly wonders if there’s anything he can fire back that will persuade me to come down and save him a load of aggro. I spend this time marvelling at a system that’s so obsessed with arbitrary targets that his reply should take this long to generate.
‘Fine. Just come when you can,’ he replies. ‘But I’m really not happy about this.’ When she’s out of the woods I must remember to have my pre-eclamptic patient write him an apology.
* Because hospitals aren’t under quite enough pressure, the government has decided that all patients in A&E need to be admitted or discharged within four hours, whether they’ve had a stroke or stubbed their toe. If more than 5 per cent of these patients breach the target (unfortunately not the type of breech that interests me), the hospital gets fined and the management unleash a heap of hell on the A&E staff.
Friday, 26 November 2010
The last of my pre-operative patients to consent before theatre is QS, an elderly lady having a hysteroscopy following some recent PV bleeding. She’s accompanied by a red-trousered roaring chin of a son. He’s under the impression that the more he treats medical staff like crap, the more convinced they will be of his importance, and thus the better treatment they will receive. Amazingly, this is a commonly held belief and, annoyingly, he’s absolutely right. People like this are exactly the type to complain to PALS if she gets so much as a chip in her toenail polish.
I bite my tongue harder with every question he asks. ‘How many of these have you done?’ ‘Is this not a case that your consultant should be doing?’ If this was a restaurant and I was a waiter, I would currently be stirring my spit and semen into his beef bourguignon; but she’s a sweet old lady, and she’s not going to suffer just because her son’s an arsehole. We’re all done. ‘Treat her as if she’s your own mother,’ he instructs me. I assure him he really doesn’t want that at all.
Thursday, 2 December 2010
Spending my Sunday afternoon on labour ward with an excellent SHO. She asks me to review the CTG of a patient and I agree with her assessment that the patient needs a caesarean section for fetal distress. They are a lovely couple, recently married; it’s their first baby, and they understand the situation.
The SHO asks if she can perform the caesarean while I assist. In theatre, the SHO goes through the layers: skin, fat, muscles, peritoneum 1, peritoneum 2, uterus. After the uterine incision, rather than amniotic fluid, blood comes out – lots of blood. There has been an abruption.* I stay calm and ask the SHO to deliver the baby – she says she can’t, there’s something in the way. I take over the operation – the placenta is in the way. The patient has an undiagnosed placenta praevia. This should have been noticed on scans, she should never have been allowed to go into labour. I deliver the placenta and then deliver the baby. The baby is clearly dead. Paediatricians attempt resuscitation but without success.
The patient is bleeding heavily from the uterus – one litre, two litres. My sutures have no effect, drugs have no effect. I call for the consultant to come in urgently. The patient is now under general anaesthetic and receiving emergency blood transfusions; her husband has been escorted out of theatre. Blood loss is now five litres. I try a brace suture† – no luck. I’m squeezing the uterus as hard as I can with both hands – it’s the only thing that stops the bleeding.
The consultant arrives, attempts another brace suture – it doesn’t work. I see the panic in her eyes. The anaesthetist tells us he can’t get fluid into the patient fast enough to replace what she’s losing and we’re risking organ damage. The consultant calls another colleague – he’s not on duty, but he’s the most experienced surgeon she can think
of. We take it in turns squeezing the uterus until he arrives twenty minutes later. He performs a hysterectomy; the bleeding is finally under control. Twelve litres. The patient goes to intensive care and I am warned to expect the worst. My consultant talks to the husband. I start to write up my operation notes but instead just cry for an hour.
* Abruption is a complication of pregnancy where all or part of the placenta separates from the uterus. Because all of baby’s oxygen and nutrients are delivered via the placenta, this can be extremely serious indeed.
† Brace sutures are very large stitches that go around the uterus like a pair of braces to compress it and stop the bleeding.
10
Aftermath
That was the last diary entry I wrote, and the reason there aren’t any more laughs in this book.
Everyone at the hospital was very kind to me and said all the right things; they told me it wasn’t my fault, said I couldn’t have done anything differently, and sent me home for the rest of the shift. And yet, at the same time, it felt a bit like I’d sprained my ankle. A flurry of people asking me ‘Are you OK?’, but also the definite expectation that I’d still come into work the next day, the reset button firmly pressed. That’s not to say they were heartless or unthinking – it’s a problem that’s baked into the profession. You can’t wear a black armband every time something goes wrong, you can’t take a month’s compassionate leave – it happens too often.
It’s a system that barely has enough slack to allow for sick leave, let alone something as intangible as recovering from an awful day. And, in truth, doctors can’t acknowledge how devastating these moments really are. If you’re going to survive working in this profession, you have to convince yourself these horrors are just part of your job. You can’t pay any attention to the man behind the curtain – your own sanity relies on it.
