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

by Rachel Clarke

  Now Brett’s brain was exposed. A hush descended as the huge operating chair from which Spetz would cut was manhandled into position. Modern binocular operating microscopes are spectacular feats of engineering that weigh around a quarter of a tonne, yet allow the surgeon to work with infinitesimal precision. He or she sits behind the microscope, peering down through tens of thousands of pounds’ worth of state-of-the-art lenses at vastly magnified vistas of brain. From here, they can manipulate an array of microscopic instruments that in time come to feel, so Spetz told me, like an extension of the surgeon’s own hands.

  Brett’s brain, illuminated by brilliant xenon light from within the microscope, was projected onto big screens around the operating theatre. Its tightly coiled terrain looked almost too sharp and bright to be real. Spetz sat hunched like a hawk over its prey, slowly but surely prising the brain away from the floor of the skull without tearing any of the minute veins and arteries that traversed every inch of its surface. Finally, he reached the basilar artery and the aneurysm itself, huge and menacing in widescreen, pulsating darkly in time with the heartbeat.

  ‘OK,’ said Spetz, leaning back in his chair. ‘That is a truly exceptional aneurysm. It’s over to you now, team.’

  So far, so good. The cardiac standstill team could now get to work. The most effective way to cool Brett down was to connect one large vein and one large artery to sterile tubing that ran through a huge vat of ice. His blood would be diverted via the tubes out of his body, through the ice and back again, becoming ever colder with each cycle. Spellbound, we watched on the anaesthetist’s monitor as, over the course of the next hour, Brett’s temperature crept inexorably downwards. His heart began to slow and beat more erratically. At around fifteen degrees, the cardiac muscle was too cold to contract properly, and his heart began to fibrillate, quivering uncontrollably. For a few moments, the ECG trace flailed wildly before silently flatlining: the heart had come to a standstill.

  At this point, but for the fact that he was cold, Brett was technically dead. All brain activity had ceased on the monitor. He no longer breathed or moved for himself. His heart was an inert lump of muscle. The anaesthetist started a stopwatch, counting down the minutes in which Spetz could safely operate before Brett’s brain would begin to be damaged irreparably from the prolonged lack of oxygen. As his blood was decanted out of his body, the aneurysm shrivelled from bulging monstrosity to empty husk. Spetz now had the space in which to manipulate its frail walls with slightly better odds of avoiding death or brain damage. As he wrestled with positioning a metal clip across the neck of the aneurysm, the theatre held its collective breath. We could only watch and hope. Finally, at around forty-two minutes, Spetz again leaned back in his chair. He had successfully clipped the aneurysm and it was time to warm up the patient.

  Hypothermic cardiac standstills combine hi-tech science with some pretty basic plumbing. In the absence of a beating heart, Brett’s blood was mechanically pumped through hot water to warm him up gradually. We watched with baited breath as his core body temperature slowly rose. For around half an hour, nothing happened. The ECG trace remained a flatline. Then, in a mirror image of what had gone before, the heart began to fibrillate, jittering chaotically on the cardiac monitor. From there, in a triumph of order over chaos that made me wonder at the physical tenacity of the human species, a normal heartbeat emerged. The heart’s inbuilt pacemaker had found its rhythm. Brett’s heart was back. At no point did the clip across the neck of the aneurysm dislodge, in spite of the high pressure, newly pumping arterial blood. Spetz had successfully dealt with the aneurysm. It was a neurosurgical triumph. We just had no way of knowing if the person Brett had survived intact.

  After major neurosurgery, anaesthetists are eager to wake up the patient as quickly as possible. Everyone is on tenterhooks to know whether he or she has escaped significant brain damage. With Brett, it was no exception. Barely an hour after he left the operating theatre, sutured, stapled and bandaged, his anaesthetic was halted and he began to come round. Spetz allowed his family to visit. Then, we too were permitted to join them at the bedside. To our astonishment, Brett’s eyes were open. He was alert and talking. It was almost impossible to believe.

  ‘Hey,’ he said when he saw me, still slurring from his anaesthetic. ‘You think the folk in Great Britain will be pleased if I say hi?’

  Journalists, like doctors, are not meant to cry on the job. But how could I not? Thanks to the extraordinary surgical skills of Spetz, his otherworldly calm under pressure, the exquisite engineering of the operating microscope, the pioneering doctors and scientists who had honed the technique of cardiac standstill, the seamless teamwork inside the operating theatre, the technology behind the heart-lung machine and, of course, a bloody great vat of ice, Brett had been killed and brought back from the dead, reborn as a man with a future. The husband he dreamed of being, the children he longed to father, the old age he hoped to enjoy – Spetz had given him a shot at them all. Tears of delight and wonder streamed down most of the faces in the room as Brett grinned at us sleepily. It was medicine at its most dazzling. Still years away from qualifying as a doctor, I could not imagine doing anything more humbling or fulfilling.

  A decade or so later, at the height of the junior doctors’ dispute, the president of the Royal College of Physicians, Jane Dacre, would strive to reach out to disenchanted junior doctors with a social media campaign that used the hashtag #medicineisbrilliant. Like many leading figures in the medical establishment, she was distraught at the disillusionment and anger unleashed by the dispute among young medics. At the time, I dismissed her initiative as out-of-touch wishful thinking. The brilliance of medicine, like the love of my job I had once taken for granted, had long since been tarnished by the barrage of attacks from the media and political spin from the Health Secretary. Being reminded of how deeply rewarding our work had used to be felt faintly like adding insult to injury. In fact, I now think she was right. From the moment I set foot inside my medical school, I was overawed by the potential of medicine – the extraordinary capacity of the human body to endure and survive serious illness, of doctors and scientists to discover new cures and, above all, of the human spirit to rise above adversity with the kind of dignity and strength at which so often I could only marvel. Medicine felt like a belated love of my life. Intoxicating, dazzling, it was indeed brilliant and I was a woman obsessed.

  CHAPTER 5

  KINDNESS

  The fourth year of my medical degree was mildly compromised by frequent dashes from the bedside to the toilet – the unfortunate consequence of mixing the smells of the ward with first-trimester morning sickness. Week by week, as my firstborn grew, all my painstakingly drawn diagrams of foetal development from past classes in embryology acquired a thrilling weight and substance. I watched with grim satisfaction as my body did exactly what my physiology textbooks predicted – ankles swelling with excess fluid, joints acquiring disconcerting flexibility as my due date fast approached. I was the first student in my medical school to become pregnant and, towards the end, continued to waddle defiantly on the morning ward rounds, daring any consultant to make a disparaging comment.

  The birth itself, though traumatic, was eclipsed by what happened afterwards. The day after my Caesarean section, still unhinged by love and bliss, helplessly besotted with my newborn son, I noticed his swaddle starting to twitch and jerk. Unwrapping the blanket revealed tiny arms and legs moving in rhythmic spasms. He was fitting – in our jargon, a tonic clonic seizure – though my treacly brain couldn’t quite compute what was happening. Somehow, while my husband ran for a nurse, I had the presence of mind to record the seizure on my smartphone. By the time the oncall paediatrician arrived, the seizure had already ended but, after he’d watched the footage, his advice was not to worry unduly but to keep a close eye in case it happened again.

  A seizure in a newborn can herald all manner of horrors – epilepsy, meningitis, a hypoxic brain injury sustained during childbirth, an intracranial
bleed or tumour – far too many a medical student mother’s worst nightmares. Even entertaining them made me feel queasy with rising panic. So I didn’t. I surrendered myself willingly to the paediatrician’s instructions. Don’t worry. Don’t fear the worst. It may be a one-off, it may mean nothing at all. Doctor, in this situation, simply had to know best because the alternative was unthinkable.

  A day of observation passed without incident. He slept, snuffled, sighed, suckled and lulled me back into a lovestruck swoon. Perhaps, on reflection, the paediatricians now wondered, the fit hadn’t been a real fit at all. A false alarm, a misdiagnosis. It felt like a reprieve – by the skin of our teeth, we’d got away with it and our son was deemed safe to go home. We started packing our bags, incredulous – as perhaps all new parents are – that the hospital could possibly be so blasé as to allow two rank amateurs who knew nothing about babies to waltz away with an actual child. Dave had just brought our pristine car seat onto the ward when, without warning, it happened again. The twitching was unmistakeable, even beneath blankets. A second seizure playing out before an audience of the three other new mothers in my bay and their three perfectly healthy newborns.

  This time, every fact, every statistic I had ever learned melted away as our infant son, head arched back, jerked and bucked before me. I couldn’t move. There was a sound in the distance, faint and ugly, that slowly coalesced into a scream. It took some time for me to understand that I was the person screaming.

  A paediatric crash team were suddenly everywhere, wresting control, stripping blankets away, pressing an oxygen mask over blue-tinged lips, applying electrodes and tubes until our son was lost beneath the paraphernalia that might hold his life in the balance. They swept him away at a sprint to the NICU, the Neonatal Intensive Care Unit, as I clung for dear life to an empty cot-side. Just as nothing had prepared me for the ferocity of maternal love, so my body’s response to the terror that my child might be dying was overwhelming and brutal. I recall not a touch or a word from anyone. Someone, a doctor, midwife or nurse must have tried to reassure me, but their words were obliterated by fear.

  We were left alone to trace the crash team’s steps through winding corridors until we found the NICU. The ward was almost too short-staffed to cope with the births, let alone spare someone to guide us. My scar was burning and I could only shuffle slowly, doubled over in pain. By the time we reached Intensive Care, a paediatrician was daubing disinfectant on our son’s exposed spine, about to perform the lumbar puncture that would rule in or out bacterial meningitis. Our baby was screaming uncontrollably, though his lungs were too small to generate much noise above the machinery, bleeping and frenetic activity.

  ‘You’d better not see this,’ someone stated in tone that invited no argument, and escorted us briskly away. Alone in a relatives room, bewildered and fearful, we waited and waited for news. I felt diminished to the point of irrelevance. For twenty-four hours, I had provided my son with everything, and now I could do nothing to help him. Other hands, other humans were tending and deciding. Cut out of the loop, we sat in silence on NHS plastic chairs, green-tinged under hospital strip lights.

  Finally, a nurse took us to the clear Perspex cot in which our son now lay, expertly swaddled, antibiotics dripping into one bandaged wrist. He was sleeping peacefully. The paediatricians were systematically working their way through my list of worst nightmares: treating for meningitis in case he was infected, scanning his skull in case he had a brain tumour, running a battery of tests on blood and spinal fluid in the hope of identifying another possible cause. He was, we were assured, in safe hands, but our world had tilted away from the sun.

  Visiting hours were long over. Dave helped me back to the ward, then drove home to an empty house. I can only imagine the night he spent there, having believed he would be home with his wife and newborn child. Myself, I lay in the darkness, shrouded by curtains, listening to three other babies that cried so lustily, fed so greedily and were cradled so lovingly in their mothers’ arms that morning couldn’t come too soon. NICU called up to the ward. Our son had had no further fits, was awake and hungry, and would I like to feed him? I made the long trek to the NICU as quickly as hobbling allowed, and held my baby at last as, with a gusto that made my inner hopes soar, he loudly demanded to be fed.

  The morning ward round was in full swing and, seeing no one to consult about where I should breastfeed, I sat in a plastic chair on the edge of the unit and awkwardly began to nurse my baby. Suddenly, I seemed to be overshadowed by men.

  ‘What do you think you’re doing?’ barked one of them. ‘You can’t do that here. What are you doing? Someone sort this out.’

  The consultant at the helm of the ward round wore a look of disgust on his face. Too shocked to respond, feeling as though I’d just committed a crime by semi-baring a breast in, of all places, a hospital, I stayed mute as a nurse swiftly erected a portable screen around me, this offensive presence in the NICU. She drew up a chair beside mine. There was something intolerable about this act of minor humiliation, coming as it did after such a brutal twenty-four hours. I felt crushed and small. And, somehow, the nurse, whose name, appropriately enough, was Precious, seemed intuitively to feel and understand everything. Tenderly, she helped adjust my son’s position on my breast and wiped away my tears. Smiling, she squeezed my hand and crooned with genuine delight, ‘Oh, my God, he is beautiful. He is perfect. He is beautiful.’

  I don’t think I have ever felt such gratitude.

  ‘Do you think so? Is he really?’

  ‘Oh, God! This boy is beautiful.’

  In fact, as even I would later concede, my son started life looking not dissimilar to Andrew Lloyd Webber, but that was entirely irrelevant. He was perfect. He was beautiful. In my eyes and now in those of Precious. She will never know what her kindness brought me. She gave me the one thing she didn’t have – her time – when her jobs must have been stacking up, piling one upon the another. Yet still she sat, stroking my hand, beaming at my newborn. We stayed that way for far too long. I’m sure it made her morning hellish. And to this day I wish I had had the presence of mind to tell her what this had meant to me. That through her kindness – freely dispensed, yet priceless – I had found cause to believe that whatever happened next, however this would end, I wouldn’t be in it alone.

  Our son left the NICU after a couple of days, a diagnosis eluding the exhaustive testing. A few days after that, he was deemed fit for discharge and finally, gingerly, we carried our car seat and baby across the hospital grounds and into our car. I remember raising an eyebrow at Dave as he drove us home.

  ‘How could they possibly have let us out with him?’ I asked. The old joke, spoken only half in jest. ‘Are they insane? Don’t they know we have absolutely no idea what we’re doing?’

  We smiled at each other, elated and terrified. We were officially a family. Ten years later my son, mercifully, remains perfectly healthy. But, a decade after we faced the abyss, the compassion and humanity of one NICU nurse remain indelibly etched in my memory.

  Until I faced the prospect of losing a child, I didn’t know what grief was. I regarded myself as reasonably empathetic and thought I could imagine what grieving must feel like. But that presumption, it turned out, was a glib one – itself a failure of imagination. I didn’t know how it could suck the air from your lungs or cause your legs to buckle or have you feverishly doing deals with a God you didn’t believe in to take you, not your child – anything in order to spare him. I’d had no idea.

  Two experiences during my five years of medical school did more to shape how I would subsequently practise medicine than anything acquired from a textbook. This was the first. It took a brush with disaster to taste how disaster really feels. I now knew how little I really grasped about the impact upon patients and relatives of the diagnoses of cancer I would one day deliver, of the news I would break that a loved one had died, of the destruction I would come to unleash as I went about my daily work as a doctor. There were whole r
ealms of pain and fear about which I knew almost nothing and never would, unless I lived something like them. I vowed never to forget that.

  More prosaically, but equally important, my brief experience as a maternity-ward inpatient had taught me how profoundly disempowering hospital could be. The quasi-knowledge I’d acquired as a medical student offered no protection against the name tags, the anonymous hospital gowns, the patient notes that everyone reads bar the patient themselves, the subtle stripping of one’s power and sense of identity. I’d hated it. It had made me feel so small and vulnerable.

  Even as I continued to amass facts at a rate that made my brain ache, I could no longer shake the conviction that something fundamental was missing from medical school. Perhaps what every aspiring empathetic doctor needs is a compulsory stint as a patient. Instead, we acquire ‘communication skills’ through workshops with actors and, if we’re lucky, opportunistic observation of real doctors having those difficult conversations with their patients.