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

by Rachel Clarke

  Today, picked up off the street by the police, he’d been brought in by ambulance with a high fever and racing pulse, rambling semi-coherently. I assessed him quickly – time was of the essence – establishing that what Mickey needed more than anything was intravenous access, a cannula through which I could take urgent blood samples and give potentially life-saving antibiotics and fluids. He was filthy, flailing and laughing at my plan.

  ‘You’ll never stand a chance of getting a needle in me, love. Not a hope in hell.’

  ‘Oh, yeah? You’ll let me have a go, though? I’m pretty sure I can.’

  Mickey found my confidence hilarious. Years of injecting had scarred his veins until accessing them with a needle was almost impossible.

  ‘I’ll give you one chance,’ he said. ‘Only one. And I bet you a gram of heroin you’ll never do it.’

  ‘A gram, you say? Right then, Mickey. You’re on.’

  If you had told me in my first weeks as a doctor that I’d come to relish the challenge of attempting to cannulate septic, trashed, sclerotic veins, I’d have dismissed your wishful thinking. New doctors are invariably inept at practical procedures, and I was no exception. Usually, we’ve practised only on plastic dummies and each other. I was lucky: I had my own live dummy to practise on. My poor, long-suffering husband, on return from our honeymoon, gamely endured his new medical student wife cajoling him into letting her stab his veins with needles. Frankly, I needed the practice. The first person from whom I’d ever taken blood, another newbie medical student, had neglected to tell me he was profoundly needle-phobic. A group of us were practising our blood-taking. As I plunged a needle into his arm, he fainted into the chair in which he was seated, becoming wedged bolt upright between its arms. Now he was thus immobilised, his plummeting blood pressure deprived his brain of its normal oxygen supply, precipitating – to my horror – a seizure. The more senior students who were gamely supervising our first efforts at blood-taking dragged him, foaming at the mouth, to the ground, where slowly he regained colour and consciousness, blood trickling down his arm from where my needle, I noted grimly, had hit its mark.

  Fast-forward a year or two and I had somehow improbably evolved into a cannula junkie who liked her veins as challenging as possible. As I scrutinised Mickey’s arms, legs, hands and feet, I could find nothing that felt as if it would yield to a needle. But there was, I discovered, one possibility. Snaking over the top of his right thumb was a tortuous yet springy vein I doubted he’d ever used before. This was my one shot. I tied my tourniquet as tightly as I could physically manage and gently nudged the needle into his thumb. A moment’s hesitation and then – flashback – blood filled the end of my needle. I was in.

  While I swiftly drew off blood and taped down the cannula, Mickey loudly extolled my virtues to the entire department.

  ‘Fuck me, she’s gone and done it! Fuck me! First time, too.’

  But I was not to be distracted.

  ‘Where’s my heroin, Mickey?’ I asked, deadpan. ‘We had a deal, remember? I want my gram.’

  As he flung back his head with laughter, exposing his rotting teeth to the ceiling lights, I wanted to dance a victory jig. I wanted the whole world to come and inspect the needle I’d precariously lodged, against all the odds, in – of all places – a drug addict’s thumb. I knew it was nothing really, that it certainly wasn’t going to survive the volumes of fluids and drugs we would need to give him, but the tiny achievement of cannulating impossible-to-cannulate Mickey made me want to punch the air with joy.

  Those first weeks and months as a floundering new doctor are peppered with moments of unexpected delight as you find within yourself new skills whose acquisition has caught you unawares. But nothing quite matches the sheer exaltation of knowing, without any doubt, that for the very first time you have just saved somebody’s life.

  A couple of months after believing I had failed my patient, Mr Frith, as he teetered on the brink of death during my first ever night on call, I was given what in hindsight felt like a chance of redemption. It was the end of a gruelling weekend on call. Sunday night, approaching nine o’clock, the start of evening handover and liberty. Tessa, my fellow house officer, and I had just spent forty-five of the preceding seventy-two hours responsible for the clinical needs of several hundred medical inpatients. We were exhausted, run ragged and desperate for it to end.

  As I worked my way through my last few jobs on the ward, twitchy and impatient to be free, Tessa bleeped me from another ward upstairs.

  ‘Rach, can you just come and have a look at this guy? He’s got pneumonia and I’ve started him on antibiotics but – I don’t know – there’s something about him that doesn’t look right. I just want a second pair of eyes on him.’

  Tessa was my friend and fellow foot soldier on the lowest rung of the medical ladder. Equally inexperienced, we were loyal comrades, united in battle – as much of our job felt like in those early days – and we would drop everything to help each other as a matter of course. But the particular words she used about her patient ‘not looking right’ sent a flicker of anxiety down my spine. I’d already learned the hard way that even the most junior doctor’s instinctive unease that something is wrong – though they may lack the knowledge or experience to delineate precisely why – can herald impending catastrophe. I rushed upstairs to find her.

  Tessa had been asked to review Mr Brewer, a man in his sixties with a new diagnosis of bowel cancer, on account of his fever and mildly low oxygen levels. When she listened to his chest, the telltale crackles at the base of one lung clinched a clinical diagnosis of pneumonia, for which she had prescribed antibiotics. Quietly writing up her entry in his notes and already looking forward to her post-on-call beer, she had noticed a change in the sound of his breathing. Mr Brewer had just returned to his bed from the toilet. Previously comfortable and chatty, he now looked distressed and pale. He denied any pain in his chest and, when she listened with her stethoscope, nothing had changed. He just looked … wrong.

  With the benefit of not having seen Mr Brewer when well, I confronted with fresh eyes a man who was obviously and horribly unwell. Tessa’s instincts were right. This was clearly no ordinary pneumonia. Something had abruptly changed. While she ran to find a nurse to bring equipment for realtime monitoring of his vital signs, I worked my way through the ‘A, B, C’ protocol that should frame every doctor’s emergency assessment.

  I knew that ‘A’, his airway, was not blocked since he could whisper, albeit almost inaudibly. I ignored, for now, the poignancy of his words, coming from a man who looked as if he was dying and worse, wore the dread of someone who knew it: ‘Please … tell my … wife … not … to worry … about me.’ I had to stay hard. There was no time to be distracted by sentiment.

  ‘B’, his breathing, was horrendous. This time, I knew the sounds all too well. Like that of Mr Frith before him, Mr Brewer’s chest had the horrible wet rasp of a patient who is drowning in his own bodily fluid. His lungs, I knew, were flooded.

  ‘C’, circulation, was no better. His hands were clammy, cold and sweaty. Where the pulse in his wrist should be, I could feel nothing at all. His blood pressure must have crashed.

  It all pointed to one diagnosis. In spite of his feeling no pain in his chest, I was certain he had suffered a massive heart attack while he had been away in the toilet. As the nurses arrived, applying wires and monitoring, I asked one of them to run for intravenous morphine and diuretics that would take the fluid off his lungs and heart. Without them, his heart would remain unable to beat properly and a cardiac arrest was inevitable. The nurse refused.

  ‘Sorry?’ I asked.

  ‘He’s got no blood pressure. If you give him those drugs, you’re going to kill him. You’re incompetent. There’s no way I’m giving them.’

  There was no time to debate the physiology, nor even to summon a crash team. Mr Brewer’s lungs were now so overloaded with fluid that blood-tinged foam had started frothing from his lips and he was slipping i
nto unconscious-ness. I – or, rather, he – had only seconds. Self-doubt couldn’t come into it. And so, almost snarling – the pressure felt so fierce – I shouted, ‘Get me the drugs! Now. I’ll give them myself.’

  It wasn’t professional, it certainly wasn’t polite, but every intuition I possessed as a doctor screamed at me to give the drugs. The nurse was absolutely right, though. If my call was wrong, my actions were probably going to kill him.

  Without hesitation, acting purely on instinct, I pushed ten milligrams of morphine straight into Mr Brewer’s vein. For a second, nothing. Then, as we all stared, aghast, the bluegrey mask of imminent death started to blossom into normal, healthy, pink flesh as blood began to suffuse his oxygenstarved tissues. It felt as if we had raised the dead, brought about a resurrection.

  As Mr Brewer’s observations started to normalise, we recorded an electrocardiogram. The ECG trace showed he had indeed suffered a catastrophic heart attack. It was only after the cardiologists had whisked him away to the Coronary Care Unit that I started to think about what I had done. It had been a risky call, based on something more intangible than a neat protocol like my ‘A, B, C’: a subtle blend of burgeoning gut instinct, pattern recognition and an understanding of the physiology of heart failure acquired in lecture rooms and libraries. Good doctoring, I’d just discovered, relied upon instinct and experience at least as much as checklists and guidelines. I felt shaky, overwhelmed by the odds I’d just naïvely managed, stricken by the what-ifs and maybes.

  The fact remained that Tessa and I had just saved a life. Had we not acted upon newly informed instinct, Mr Brewer would have almost certainly arrested. I’d love to pretend that we reflected deeply and wisely on this clinical experience, but I’m afraid we couldn’t stop beaming. We walked out into the night feeling like real doctors at last – decisive, brave, going with our guts, just like the white-coated heroes on television. Later, drunk on euphoria and vodka, we sat up half the night, compulsively reliving the case in minute, obsessive detail. We felt – in our naïveté – temporarily invincible. For one night only, in our minds, we ruled the hospital.

  In medicine, needless to say, the moment you feel as if you’ve mastered something is invariably the point at which your next experience will knock you straight back down to earth. But during the ups and downs of my first year as a doctor – the mercurial lurching from disappointment to fulfilment, elation to despair – I started to assemble within me a collection of faces that gave me ballast and solidity, whatever the day threw my way. These were the patients with whom, as our paths briefly crossed, I had formed a human connection that proved quietly to endure.

  It didn’t take much to make a difference. During a gruelling stint on the Surgical Emergency Unit – a wild west of pre-operative and post-operative surgical patients whose house officers were largely left to fend for ourselves while our seniors got to work cutting in theatre – a nineteen-year-old on our early-morning ward round caught my eye. Ellie had been rushed to theatre the day before to remove a grossly inflamed appendix. Now, despite the good news that she could go home later that day, she looked anxious and uncertain. As my consultant swept imperiously to the next patient’s bedside, I whispered, ‘I’ll come back and have a chat with you.’

  Later, when we spoke, I discovered Ellie was distraught at not being able to pass urine since her catheter had been removed earlier in the morning. Though her bladder was increasingly tense and painful, still she was unable to empty it. All it took was a five-minute chat. I taught her the tricks that can sometimes help – running a tap, putting a hand in hot water – and described my own mounting distress, after a Caesarean section for my first child, when I thought my newborn and I were never going to leave hospital simply because I couldn’t get my bladder working. With a little encouragement from the nurses, Ellie left for home by lunchtime. Some weeks later, a handwritten card arrived at the nurses’ station in which she thanked me for my kindness. It had been nothing, a five-minute attempt at empathy, but it had meant something important to her.

  Occasionally, I found myself drawing on qualities honed not in medical school but during my old life as a journalist. In the hunt for the story, tenacity, doggedness and a stubborn refusal to take no for an answer were essential tools of the trade. I never anticipated how integral they would prove to be in navigating effectively the creaking, dysfunctional hospital bureaucracy. Only rarely was a patient’s outcome in my control. Usually, getting something done meant managing and sometimes deliberately circumventing arcane systems that often seemed designed to waste our time and thwart good patient care. Hospital computer systems that were unfit for purpose; scan results that were accessible only to the team that performed the scan and not you, the doctor who requested it; a switchboard so desperately understaffed you could have whipped out an appendix in the time it took someone to answer. Sometimes, I felt less like a doctor than a paper-pushing, clipboard-carrying, largely ineffectual secretary.

  With one patient, my persistence became an obsession. While I was still on the Surgical Emergency Unit, someone arrived whose military precision was the antithesis of the chaos, stench and racket of the ward. Major Robert Ashdown was a recently retired army officer who, in a week’s time, was due to climb Mount Kilimanjaro with his daughter. He had awoken that morning in crippling abdominal pain and been rushed by ambulance to the unit. Now, my examination revealed a classic ‘acute abdomen’ – exquisitely tender to touch and protected by utterly rigid abdominal muscles, a clue that blood or infection was irritating his abdominal cavity. Through gritted teeth, he exhaled quietly as I pressed gently down on his belly. Anyone else would have screamed. It felt like palpating hardwood.

  ‘I’m so sorry,’ I told him. ‘I have to do this to help make a diagnosis.’

  ‘You do exactly what you need to,’ he ordered. ‘Carry on.’

  Immaculately dressed, with the kind of posture that made standing to attention look like slouching, he was experiencing his first ever hospital admission. An urgent CT scan revealed a large amount of fluid around his stomach and the profound anaemia on his blood tests indicated the fluid was almost certainly blood. We put in a tube that drained litres of the stuff away; however, slowly but surely, it kept on coming. Every time the bleeding appeared to have finally settled, it would start to ooze, then flood again and I’d be straight back on the phone to the blood bank.

  Throughout it all, Major Ashdown’s wife and three daughters kept a restrained vigil at his bedside, equally immaculate and reserved. Not one of them expressed distress or fear. Eventually, with a diagnosis still eluding us, my consultant had no choice but to take him to theatre. The surgery revealed a gastric cancer, hidden beneath the huge blood clot, that had invaded the local blood vessels, causing bleeding too widespread and diffuse to fix. There was nothing to do but pack the abdomen tightly with gauze and stitch it back up again, temporarily staunching the bleeding, then keep Major Ashdown comfortable until it inevitably restarted.

  ‘How long do I have?’ he asked the surgeon that evening.

  ‘I can’t say for certain, but I would estimate at most a handful of days. It’s only pressure that’s stopping the bleeding. I’m afraid there is nothing we can do.’

  There was something uniquely horrible about the situation. Perfectly lucid and composed, in only mild discomfort from his abdominal incision, Major Ashdown confronted the fact that, at an unspecified time in the next two or three days, he would begin to bleed from his tumour and, when it started, he would haemorrhage to death.

  Late that night, just before setting off home, I called in to see him. His family had gone to eat dinner and we chatted about what was to come.

  ‘Where would you like to be?’ I asked him. ‘Would you like to get home or prefer to stay here?’

  ‘I don’t think my wife would be able to bear the bleeding happening at home,’ he said, ‘but there is one place I think I’d like to be.’

  Our local hospice was renowned for the excellence of its dri
nks trolley. If there’s one thing the terminally ill deserve, it’s a fine vintage with their lunch or dinner. Major Ashdown was currently trapped on a frenetic, raucous surgical ward with its relentless soundtrack of bleeping, clattering, moaning and shouting. What he longed for, in his final days, was somewhere peaceful and calm where he could be with his family and be expertly looked after when the bleeding began. There was one problem. Beds in the hospice were like gold dust. To earn one, you needed symptoms that were too difficult and distressing for GPs or ordinary hospital wards to manage. Major Ashdown was entirely asymptomatic. Yet he faced, albeit with apparently total stoicism, certain death in just a day or so. I couldn’t pretend to imagine the psychology of that.

  ‘I can’t promise anything,’ I told him, ‘but I’m going to do my best.’

  The next morning, in between the thousand and one other jobs I was juggling, I started making calls to the hospice. Initially, I explained the situation to a ward nurse. She sympathised, but said he wouldn’t meet the criteria. After some shameless cajoling and begging, she agreed to pass me on to the ward doctor. Same conversation, same scepticism, but a reluctant agreement to let me speak to her senior registrar.

  By now it was late afternoon. I wished I had never said anything to Major Ashdown. His family were ecstatic at the idea of the hospice bed it was not in my power to give. ‘We know you can do it, Rachel,’ they told me. I knew I almost certainly could not. A tense conversation with the hospice registrar ensued. It was a no. I lobbied and argued and finally, reluctantly, she agreed to let me speak to her consultant. Few phone calls had mattered to me more.