Your Life In My Hands--a Junior Doctor's Story

by Rachel Clarke

  Amid the standard torrent of bleeps from the nurses summoning me from one patient’s bedside to another, I’d answered a call from the cancer ward. Unusually, a patient had arrived by ambulance in the middle of the night, requiring admission for end-of-life care. Such admissions tend to be planned in advance, ensuring dying patients are not subjected to gruelling journeys during antisocial hours. No one was quite sure why this patient had turned up when she did.

  ‘Of course,’ I chirped brightly, ‘I’ll come right away,’ while inwardly cursing the miserable luck of having to admit a patient for palliation during the early hours of the morning. It’s not that I have no heart whatsoever, but that nocturnal firefighting for fourteen or fifteen hours straight leaves time and energy only for emergencies. When one doctor is on call for several hundred patients scattered up and down the hospital, reaching those with strokes, bleeds, heart attacks and life-threatening sepsis before they come to further harm requires ruthless, robotic efficiency. Tender loving care is all but ripped out of hospitals at night by the shoestring staffing. Now, in the midst of the usual mêlée, a patient had arrived who was actively dying. They’d need hospice-style care – limitless compassion, patience and time – that was simply not in my power to give, enslaved as I was to my incessant pager.

  Before entering the patient’s room, I asked the nurses to hold my bleep. ‘Please only interrupt me for crash calls and emergencies,’ I asked, anticipating finding someone in uncontrolled pain, potentially facing the end of her life with neither dignity nor solace.

  Instead, the room was perfectly silent. Various family members obscured the patient, crouched like supplicants around the bedside, shoulders heaving with inaudible sobs. A mother, father, sister, brother and, as they drew back, the patient herself, a young woman in her early twenties. I felt more an intruder than a healer, invading collective grief as thick as blood. The family turned to me as one, eyes bright with tears and the expectation that I could give them something, anything. In one glance, I knew I could not. My patient had end-stage cervical cancer. Too young to be approaching death, she looked gaunt, defeated, as exhausted by the effort of remaining alive as it is possible to be while still living. Her eyes met mine. Not once before had I seen anyone so tired, so tenuously connected to life. Bleached and waxen, she was as insubstantial as air. I knew she knew as clearly as I did that she was dying. Words were superfluous; her look said it all.

  Anticipating the effort it would take her to speak, I too crouched down low by her bedside, gently taking her hand.

  ‘My name is Rachel,’ I said. ‘I’m your doctor and I’m here to help you. It’s Sarah, isn’t it? Please tell me, if you can, how you are. And how I can help you.’

  Slowly, as if summoning all remaining strength, she shook her head imperceptibly. Then, a barely audible whisper. ‘You can’t.’

  I felt redundant, incapable, too inept to make things better.

  ‘Are you in any pain?’ I asked quietly. Another faint shake of her head. ‘Is there anything making you uncomfortable?’ Another. ‘Is there anything you need me to do?’ Another.

  She allowed me to conduct the briefest, most cursory version of an examination I felt I could safely manage. Cancer had stripped her to skin and bone and I knew any movement of her uncushioned frame might cause her unnecessary pain. Her breathing was shallow and rattled. Her heart murmured in between beats as it worked above the odds to keep her blood in motion. Her belly, though grossly swollen with fluid from the cancer, was not unbearably tense. Her skin was intact, her peripheries warm. I found nothing requiring immediate intervention.

  As patients approach the end of life, the same symptoms tend to prevail. Pain, of course, often predominates but, in a great many cases, modern medicine has found ever more ingenious ways to control even the most intractable of pains. Breathlessness, too, is common, as lungs fill with fluid, tumour or infection. Managing agitation, anxiety and fear is the third great challenge in palliative care, since the so-called ‘anxiolytics’ – anxiety-lulling drugs – can also, in high doses, leave patients too drowsy to be fully aware of their surroundings.

  My patient appeared neither anxious nor in pain. Still, I needed to make sure. I asked her directly, ‘Sarah, are you frightened?’ Another minuscule shake of the head. I wondered whether overwhelming fatigue had obliterated any feelings of fear. Perhaps she had come to see death as a release from the ordeal – the sheer slog – of still living. Though her death was clearly imminent, for now she appeared free from distressing symptoms. I asked her if she was willing for me to talk to her family and, with her murmured assent, we adjourned to a typically tiny NHS relatives’ room.

  My patient, at age twenty-four, had lived with her cancer for over a year. Radical, disfiguring surgery had failed to eradicate the tumour, which, it later transpired, had already infiltrated distant parts of her body. Though chemotherapy had given her extra time, it had offered no prospect of cure. Her mother, impassive, led the discussion, while her two siblings cried with heads bowed, and her father faced the wall, looking away from me. A third sibling was abroad in South America, and Sarah’s mother said he would drop everything to come home immediately if there was any danger of Sarah dying.

  Doctors try to avoid rash prognostication. If we cannot judge accurately someone’s life expectancy – and all too often we can’t – we are loath to offer what may prove to be misleading speculation. Junior doctors in particular, lacking the years of experience that hone our older colleagues’ instincts for a patient’s survival, are acutely conscious of our limitations. I was very junior, only four years into my training. But it was two or three in the morning, and Sarah’s mother had asked a simple but important question. Should her son catch the first flight home?

  I didn’t have to give an honest answer. I could have fudged it, exploited my inexperience to defer a difficult conversation until my more erudite colleagues arrived in the morning. But that felt like the coward’s option. Incapable though I was of giving any consolation, at least I could give them the truth. So, after important caveats about the challenges of making accurate prognoses, I said that, yes, Sarah’s brother should catch the first plane he could, because his sister was very, very unwell. It was possible she could die very soon. Indeed, I would not be surprised if she failed to survive the next few days.

  Time hung still for a moment, then the room reverberated with grief. Shrieking, sobbing, a family howled its despair. Sarah’s father punched the wall over and over, moaning and shaking his head. I sat stricken with horror at the emotion I’d unleashed. He turned to face me, almost snarling with anger.

  ‘You will not dope her up. You won’t take her away from us. I will not allow you to drug her. I swear to God, I will kill you if you drug her.’

  The rest of the family turned on him.

  ‘Dad,’ shouted the sister, ‘the doctor’s not going to drug her up. She just wants to make sure she’s comfortable.’

  The father responded by pounding fist against brick more aggressively. His wife screamed at him to stop. As accusations flew back and forth between family members, I felt like a crumb in a maelstrom. I knew it was cancer, not me, that had ripped their world to bits, but that didn’t stop me feeling responsible. Trying to give them time to assimilate the prognosis, I retreated outside to write in the patient’s notes. Perhaps I was trying to hide.

  On returning, I found rage had subsided into slumped resignation. Still Sarah’s father wouldn’t look me in the eye, but now he wept quiet tears with the rest of the family. I talked about the delicate balance between minimising distressing symptoms and ensuring a patient remained as alert as possible. How my overriding priority was Sarah’s comfort. That I would strive, I promised, to ensure the end of her life was the best it could be. We discussed the manner in which the next hours and days might unfold. Finally, words ran dry.

  On the brink of departing, I found my hand hovering uncertainly above the door handle. I had decimated this exceptionally devoted family
and I wanted, I think, to atone for this.

  ‘I – I hope you don’t mind,’ I said to Sarah’s mother. ‘I’d like to say something to you before I leave.’

  She stood up and we confronted each other. As I spoke, slightly nervously, light-headed with the risk of it, her eyes never left mine.

  ‘When I first arrived in Sarah’s room tonight, I saw two things. First, I saw a patient who was as ill as it is possible for someone to be. You know I didn’t need to be a doctor to see how unwell your daughter was. But I saw something else as well. I saw someone who was surrounded by love. You were all there, and you were giving her what she needed more than anything. You were surrounding her with love. I’ve seen many people die alone. But Sarah is not. She knows she is loved. Because of you.’

  It could have been mawkish, crassly inappropriate. But it was, undeniably, true. I have held the hands of too many elderly, forgotten patients, sole witness to their final exhalation in the absence of family and friends. That an entire lifetime can be reduced to this – an end so inconsequential that not one person mourns or even notices – never fails to appal me. Sarah’s mother, to my surprise, stepped forwards and embraced me, tears streaming as she thanked me.

  I was spent. I left before I too started crying.

  At the nurses’ station, the list of new jobs I’d accrued since depositing my bleep covered most of an A4 sheet of paper. My heart sank. I’d be playing catch-up all night. As if on cue, my crash bleep crackled into life. ‘Adult cardiac arrest team. Adult cardiac arrest team. Ward 6A. Crash call, ward 6A.’ The Nights God had decided to play dirty. ‘Aw, I was going to make you a cup of tea after that,’ said the night sister kindly as I ran, cursing inwardly, down the corridor.

  Around this time, the Medical Director of NHS England, a heart surgeon called Professor Sir Bruce Keogh, was starting to make waves in the media with his talk of an important new mission, a ‘seven-day’ NHS. Only that weekend, the papers were full of his quotes, each glaringly omitting to mention how anyone would actually pay for his visionary new seven-day service.

  Several hours, the crash call and a small mountain of jobs after my encounter with Sarah, I paused for a few minutes to slurp caffeine in Diet Coke form, my drug of choice on night shifts. I glanced at one of the headlines about Keogh and something in me snapped. Only an NHS apparatchik singularly disconnected from the overstretched NHS front line could possibly push for seven-day services in the absence of seven-day funding. In five minutes, through a haze of rage, I found I’d hammered out a draft of a letter to a national newspaper. Over the coming weeks and months, I weighed carefully whether or not to submit the letter for publication. On balance, I decided that highlighting my concerns about the potential costs to patients of an unfunded expansion of services was not only defensible but necessary, since my first duty as a doctor was always to act in the best interests of my patients. The letter read:

  Dear Sir,

  It is 4 a.m. and I am a junior doctor writing from a weekend night shift at a respected teaching hospital. I have run arrest calls, treated life-threatening bleeding and sepsis, held the hand of a young woman dying of cancer, tried to comfort her family, scuttled down miles of dim corridors occasionally wanting to sob with exhaustion, forgotten to eat, forgotten to drink, drawn on every fibre of strength I possess to keep dispensing compassion, kindness and, above all, good medicine to my patients this never-ending night.

  And right now, huddled over a Diet Coke and a laptop, I am struck by the utter absurdity of the fantasy politics played by Professor Sir Bruce Keogh, government and opposition alike that a seven-day NHS is possible without an appropriate increase in funding.

  Do they really not know how desperately thinly we are stretched? I don’t think so. The maths is simple. Pretending that the NHS can provide a seven-day weekday service without funding it isn’t just disingenuous, it is downright dangerous for patients.

  Yours sincerely,

  Dr Rachel Clarke

  I wouldn’t know it for many months, but this letter, when published – to the considerable ire of the hospital I worked in – framed the essence of many junior doctors’ opposition to Jeremy Hunt’s seven-day crusade. It certainly wasn’t hostility to better weekend services per se. Although the evidence on the ‘weekend effect’ was debatable – some studies demonstrating an increase in deaths at the weekend, others showing no increase in weekend mortality – the fact remained for me that I would dearly love weekends to be better resourced in my hospital. Junior doctors know better than anyone that, while some parts of the hospital, such as Accident and Emergency, are equally staffed every day of the week, most hospital inpatients are looked after by a skeleton crew of doctors whose main objective is to attempt to keep their patients safe until Monday morning, when full routine services resume. Patients can sit in a two-day limbo, denied non-urgent scans and other investigations through lack of weekend capacity.

  But where we differed from the politicians was in the knowledge that beefed-up weekend services could not be manufactured from spin alone. They needed resourcing, they needed staffing. From the front line, it was perfectly clear that the primary barrier to better weekends was not contractual change in our terms of employment but the finite number of NHS doctors, nurses and other allied health professionals. Without additional medics, there were only two ways to roster more of us at weekends: either take us away from our patients Monday to Friday, or force us to work longer overall hours. I failed to see how either option could possibly have patient safety at its core.

  At ten o’clock that morning, punch-drunk with fatigue, I finally set off home. Driving post-nights can be fraught. Several junior doctors in the UK have died in recent years after falling asleep at the wheel. Indeed, the journey home after my first ever Easter weekend on call was very nearly the death of me. In the split second during which my eyelids drooped, I crashed my car headlong into a stationary vehicle, somehow emerging unscathed from the wreckage. On the morning after meeting Sarah, however, I pulled over for a different reason. Not because my eyes were closing but because, without warning, I’d found myself blinded by tears. I hadn’t cried all night but now, in a dual carriageway lay-by, still dressed in trainers and my stinking scrubs, I thought I’d never stop.

  She was more than a decade younger than I was, with a cancer that had consumed her before her parents’ eyes. Attempting to help them that night, while keeping all my other patients safe, had required enormous stamina, yet failing to do so had not been an option: it would have felt inhuman. And this was nothing special. This was routine, everyday stuff. This – in one night – was the NHS front line. Threadbare, scrappy, perilously understaffed, decent, bloody-minded, barely held together by the indefatigable legions of nurses, doctors and allied health professionals not asking for thanks or expecting recognition, but simply getting on with it, heads down. A thousand such scenarios played out across our hospitals day in, day out, up and down the country.

  Against this backdrop, on 16 July 2015, Jeremy Hunt chose to take an axe to doctors’ efforts at caring. He portrayed us, quite deliberately, as lazy and grasping. It was as calculated as it was aggressive.

  Smarting, astonished, furious, the front line was about to fight back.

  CHAPTER 2

  DEEDS

  Until the summer of 2015, I was the kind of social media ingénue who befriended only actual friends on Facebook, followed approximately three people on Twitter, regarded what teenagers got up to on Snapchat as apocalyptically terrifying (would my children really be sexting within the decade?) and certainly didn’t know what a ‘meme’ was. Whenever a photo of a cute cat appeared on my Facebook timeline, inexplicably ‘liked’ by 2.3 million people, my overwhelming emotion was exasperation. As for WhatsApp, that sounded sinister – a bit too much like Snapchat for my taste.

  But, the weekend immediately after Jeremy Hunt’s opening salvo against doctors, even a crusty old Luddite like me would feel energised by the power of social media. An anonymous ju
nior doctor devised a consummately modern response to Jeremy Hunt’s claims about doctors not working weekends: a hashtag. Due to spend thirteen hours at work each day on the Friday, Saturday and Sunday immediately after Hunt gave his speech, the doctor in question coined the perfect slogan. It simply read: #ImInWorkJeremy.

  The doctor launched his campaign on the Friday evening. Within hours, Twitter and Facebook were overwhelmed with #ImInWorkJeremy selfies from junior doctors, consultants, nurses and paramedics at work in hospitals and general practices all over the UK. An impromptu eruption of grassroots defiance, this was NHS staff nationwide giving a collective two fingers to a Health Secretary who had presumed to scare the unsuspecting public with the erroneous notion that the NHS wasn’t there to look after them seven days a week.

  Thousands of health workers joined in as #ImInWorkJeremy became one of the top-trending hashtags that weekend. Inevitably, the mainstream media picked up the trend, with the national press running stories throughout the weekend on how ‘NHS staff turned to Twitter to condemn Jeremy Hunt’, as the Daily Mail put it.4 #ImInWorkJeremy had officially gone viral.

  Hunt’s PR team at the Department of Health, presumably rattled by the ferocity of the backlash against him, decided to attempt social media spontaneity themselves. And so, on the Saturday morning, Hunt set out to promote his own weekend working credentials by tweeting a picture of himself with a neurosurgical team at University College London Hospital. The accompanying text enthused: ‘Fascinating visit 2 see brain surgery at UCLH and inspirational leadership of Neil Kitchen. Thx 4 making me welcome [sic]’.5 Alas, in an unfortunate own goal, the photograph he posted included a whiteboard listing the full names of the patients on the neurosurgical ward he attended. Hunt had just tweeted them to his then seventy thousand followers, an eye-watering breach of patient confidentiality. Though the picture was swiftly edited to take out the compromising information, enraged doctors – for whom protecting patients’ confidence is a deeply ingrained imperative – clamoured en masse for an apology. As one, Lauren Nicole Jones, put it on Twitter: ‘If I tweeted a photo with patient identifiable information to over 70,000 people I would deserve to lose my job as NHS worker.’6 Perhaps Hunt apologised privately to all the patients concerned, but in public no such apology was forthcoming.