‘What’s been going on then?’ I asked Donna.
‘Well, when I eat, I always feel sick. I think there’s something wrong with the gastric band. I’m not even losing weight.’
Even without a gastric band I think that eating an entire chocolate cheesecake for breakfast would have made me feel a tad nauseous. Thanks to a bariatric operation, my patient had a band restricting her stomach to only a quarter of the normal capacity. If today’s breakfast was representative, of course she was going to feel sick after meals.
‘Who put the band in?’
‘The NHS wouldn’t do it so I had to go private, but I can’t afford to go to see them again. It cost me a bloody fortune to do it in the first place. What a waste of money.’
Looking through the notes I could see that Donna had come in many times over the last few years requesting help with weight loss. A previous GP had referred her to have a gastric band fitted on the NHS, but the request had been rejected because she didn’t fulfil the criteria: patients need to have spent at least two years trying to lose weight through exercise and diet programmes. Clearly not prepared to wait, Donna had found the money to get the op done privately.
I’m not against the idea of weight-loss surgery being performed on the NHS. Ideally we would all be slim and healthy due to vigorous diets and abundant exercise, but the reality is not that straightforward. Many people simply can’t manage to control what they eat and so end up overweight. When the weight starts getting to dangerous levels, a gastric band can completely turn someone’s life around. Some might argue that the cost of the procedure should never be fronted by the taxpayer, but successful gastric band operations can often cure expensive diseases such as diabetes and high blood pressure, returning to health and work people who were previously facing a future of illness and disability. The potential savings to the taxpayer are enormous.
Most patients who have a bypass operation simply can’t manage big meals any more. They feel full and sick if they eat too much, and soon learn to lessen their portion sizes. But I guess Donna was finding that old habits die hard.
‘Donna, I don’t think you need to see a surgeon. The gastric band is doing what it’s supposed to do.’
‘But this band makes me feel sick all the time.’
‘No, you will feel sick if you try to eat as much as you did before the operation.’
‘But I never really ate much anyway and now I eat even less.’
Donna looked suitably insincere – so much so that I didn’t feel I needed to mention that I had witnessed her choice of breakfast that morning.
‘Let’s make a deal. I want you to promise that you’ll make a massive effort to eat much smaller portions of food for the next two weeks. If you can do that but find you are still feeling sick I’ll refer you to the surgeons on the NHS.’
Donna nodded with what I took to be genuine earnestness, and, sure enough, she didn’t return. I’m hoping that next time I see her, the nausea will have gone and along with it some of the weight.
Karen’s baby
I like doing antenatal checks; it is one of the few times during my day that a patient isn’t coming to see me because they are unwell. The process of measuring pregnant tummies, listening to foetal heartbeats and having chats about baby preparations is a lovely part of my job. Karen’s appointments had been no exception. She was very excited about the arrival of her first child. The pregnancy had been normal and her antenatal appointments with me had been unremarkable.
I only got wind that something had gone wrong when I received a letter from the hospital. Karen’s waters had broken a few weeks early, and her baby had then started to show signs of distress during the later stages of labour. The hospital team had initially tried to use forceps to get her baby out and then went on to perform an emergency caesarean section. They discovered the umbilical cord was wrapped around his neck. When he was finally delivered, the baby didn’t start breathing. The paediatric team tried to resuscitate him with oxygen, and when he still didn’t breathe he was put on a ventilator and rushed to the neonatal intensive care unit.
It was touch and go for several days, during which Karen barely left his cot side. Her baby son Wesley had been starved of oxygen for too long during the birth, and it had caused some damage to the brain. Ironically, by a mechanism I don’t fully understand, the oxygen that was then given during the resuscitation period to keep him alive went on to cause further brain damage. The brain scans confirmed that quite extensive damage to Wesley’s brain had occurred, but the neonatal specialists explained that only time would tell how severely disabled he really was.
It was several months before I met Wesley for the first time. He had been kept in the special care baby unit for 12 weeks and there were all sorts of ongoing problems. For Wesley to leave hospital he needed to have a mobile oxygen supply and also a special feeding tube that went into his stomach via his nose. I popped in to see how they were getting on on my way home one evening. ‘He’s gorgeous,’ I said, as I peered down at Wesley in his specially modified cot. If I’m completely honest, he wasn’t gorgeous. He was odd looking with a large forehead and bulging eyes. He could sometimes focus on light in the way that a baby a few days old might, but he wasn’t smiling or showing the sort of interest in the world that a normal three-month-old would.
Karen looked down at her son with immense pride, and it really moved me to witness the overwhelming strength of a mother’s love. From the outside all I could see was an abnormal-looking disabled baby, but the maternal bond she had with her son was as strong as any mother’s could be.
As I stared down at Wesley, his eyes wandered aimlessly in different directions and I wondered just how much he would develop over the months and years to come. As a parent myself, I can’t possibly imagine how it would feel to care for a severely disabled child. My fatherly love has always been quite selfish. I’ve always adored my children, but it wasn’t until they started giving me something back that I really began to fall in love with them. The sleep deprivation and constant screaming drove me to distraction until that first precious smile melted my heart. I was completely enthralled when my children started to grab things and then roll over, sit up, crawl, babble, talk and walk. These are all just normal developmental milestones that we reach, but for me, I needed those milestones to make the purpose of parenthood tangible. Would I be able to love and care for a baby like Wesley who might never reach even the most basic stages of human development? I would like to think I could be as amazing as Karen and offer unconditional parental love, but I’m not so sure. I guess until faced with the same scenario, none of us can be completely sure how we would react.
Over the coming months Wesley remained stable. So, when he reached four months old, Karen was able to take him on outings to meet up with other mums with similarly aged children. Most normal four-month-old babies still don’t do a great deal, so the contrast wasn’t too marked. As the months passed, however, the difference between Wesley and the other babies became much more obvious. Though Wesley grew in size, he continued to lie passively like a newborn while his peers starting sitting up and babbling. He was also having regular seizures, which would upset the other mums. The obvious contrast between Wesley and what was considered ‘normal’ was becoming too much for Karen to bear. She started to withdraw herself and Wesley from the world and spent more and more time at home. She had to tell her boss that she wouldn’t be able to return to her job after her maternity leave ended, because she didn’t believe that anyone else would ever be able to look after Wesley and provide him with the care he needed. Her relationship with her husband also started suffering.
One day, she came to see me asking for counselling and an antidepressant. Her love for Wesley remained as strong as ever, but the rest of her life seemed to be crumbling around her.
I spent a brief period working in obstetrics in Mozambique early in my career. Most of the babies seemed to pop out with minimal intervention needed, but, as in this country, there were
times when things went wrong. I can remember one occasion when a baby boy was born like Wesley with the cord around his neck. The midwife wiped him down and gave him a few pats, but he didn’t start breathing. In a slight panic I rushed over to get the oxygen. Mo, one of the local doctors, put his hand on my shoulder as if to say ‘stop’. There were no ventilators or intensive care units where I was working, but there was some oxygen and a face mask. I didn’t understand why Mo wouldn’t let me at least give it a go.
‘His brain has been starved of oxygen for too long,’ Mo calmly told me. ‘It wouldn’t be fair to try to revive him.’
I was shocked at Mo’s attitude. He had been such a caring and compassionate doctor up until now. Surely this baby deserved a chance?
I ignored his advice and took the baby over to the oxygen machine and fitted the tiny oxygen mask over his face. As I was struggling to turn on the oxygen cylinder, I could feel the baby’s mother’s desperate eyes watching my incompetent fumbling. Mo came over and calmly took control, expertly performing neonatal CPR on the tiny motionless little boy. We kept going for several minutes but stopped when it became clear that we were not going to save him. All the way through the resuscitation, the mother had watched us in complete silence. When we finally stopped, she started wailing. The cries were so loud you could hear the unrestrained anguish. Mo wrapped up the lifeless baby in a towel and handed it back to the grieving woman before we made a shamefully quick exit. I couldn’t bear to hear that raw grief, so I walked further and further away. It was a painfully long walk before I could no longer hear her.
Over a beer later that evening, Mo tried to explain to me why he hadn’t wanted to attempt resuscitation. ‘These people are very poor,’ he explained. ‘They can’t afford to have a disabled child who won’t be able to look after himself. That mother needs to be able to work to feed the other children, but she wouldn’t have been able to if she had a disabled child. The whole family would suffer.’
‘But surely it’s not for us to make a decision based on this?’ I countered.
‘No, it is God’s job to decide and he made his decision when he put the cord around the baby boy’s neck.’
Sometimes I wish that I too believed in God so that I could justify some of the terrible things I’ve seen as simply being a divine will.
However much pain and hardship Wesley has caused Karen, I’m 100 per cent sure that she wouldn’t for a moment wish that he hadn’t been resuscitated. While resuscitated babies are left with varying degrees of disability, others make full recoveries. I would like to think that we should value the lives of all these children, but I sometimes wonder if there might be a point when quality of life would appear so limited that we question the ethics of artificially maintaining life. As a doctor, I can’t give an answer to when this point should be any better than anyone else. Wesley is now nearly two years old and he is still at the developmental stage of a newborn baby. Karen tells me he seems to like it if she plays him music and gently rubs his tummy. Is that a quality of life worth all the suffering? Karen would say yes. I’m not so sure.
Notes
Several reviewers of my first book suggested that the funniest part was the section on medical notes. I could be a little offended, as this was the only chapter in which I made absolutely no creative contribution. However, given its popularity, I thought I would offer a few more humorous excerpts apparently extracted from genuine medical records:
1. The patient left the hospital feeling much better, except for her original complaints.
2. Patient’s fluid intake is good, mostly beer.
3. Patient has neck veins distended down to ankles.
4. I will be happy to go into her GI system; she seems ready and anxious.
5. The patient states there is a burning pain in his penis that goes to his feet.
6. Her leaking occurs with coughing, sneezing, and exercise such as running. She would like to do more exercise, but the incontinence inhibits her. She does, however, carry on water sports.
7. She has been informed that she is pregnant by her GP.
8. Kindly see four-year-old James, who has had a cough since yesterday. Also, the family pet dog has had a similar barking cough for the last few days.
9. I should be grateful if you could see Mrs Y, who has halitosis of both great toes.
Nurses I
I had just arrived for my A&E shift, and to my pleasant surprise the department looked relatively calm in comparison to a normal Friday evening. There were no trolleys in the corridor and even some of the cubicles were empty. ‘Doesn’t look too bad,’ I remarked to Sian, one of the nurses. ‘Don’t jinx it,’ she said. ‘I really need to finish on time tonight. It’s my daughter’s 10th birthday and I promised her I would be home before she goes to bed. I always seem to be working on her birthday.’
The evening wore on and it was just how I like it: a constant stream of patients coming in and out but none of the frantic chaos that so often accompanies working in the emergency department. A couple of hours into my shift I was asked to see Bill, an elderly gent who was confused and agitated. Clara, his worried daughter, was trying to calm him down, but in his confusion he was just mumbling a few words and continually trying to pull off his oxygen mask. Clara had been trying to persuade her dad to see a doctor for months but he had steadfastly refused. He had been stoically ignoring a horrible-looking infected ulcer on his foot. But it had got so bad that the infection had taken hold and he was now too unwell to object to being brought to hospital by the paramedics.
Bill was dehydrated; I needed to put in a drip so that we could give him some fluid, but every time I thought I had calmed him down enough to put in the needle, he would jerk his arm away at the vital moment causing the needle to burst his vein. Searching his arms, I realised I was running out of good veins. I was going to need some help.
‘Sian, could you just give me a quick hand?’
‘Sorry, Ben, my shift finished 10 minutes ago and I really need to get away on time tonight.’
I quickly scanned the area, but there was no one else free.
‘I just need you for two minutes. I can’t get a cannula in this patient. Could you just hold his hand and keep his arm still?’
‘Two minutes!’ Sian repeated sternly before she reluctantly followed me into Bill’s cubicle.
Ten minutes later I was still trying to find a decent vein to cannulate. Thankfully, Sian was doing a sterling job keeping Bill calm and, most importantly from my point of view, holding his arm still. She was even chatting away warmly to his daughter Clara and helping to distract her from how poorly her father was. To all of our relief, I finally got the needle into the vein and gently slid the cannula in place.
‘Thank you so much, Sian. Just keep his arm still for 10 seconds longer while I find some tape to really secure this cannula – I don’t want him to pull it straight out.’
Just as I began to turn round, Sian grabbed my arm. I twisted back to find Bill had suddenly slumped forward and let out a gasp. His eyes, which had previously been shut, were now open.
‘BILL!’ I shouted, grabbing his wrist, but there was no response and no pulse. Within a moment Sian had shouted to the ward clerk to put out a crash call and lowered the bed flat so she could start chest compressions. When the rest of the doctors came running, Sian let someone else take over and gently shepherded Clara out of the cubicle and into the relatives’ room. I stayed with Bill and we carried on doing our best to resuscitate him.
I wish Clara hadn’t had to witness that first stage of CPR. However many times I’m involved with a resuscitation attempt, the brutality of chest compressions is never lost on me. The force needed almost always cracks ribs, and I would hate to witness it being carried out one of my loved ones.
The anaesthetist skilfully intubated Bill while I was still doing chest compressions. After each two-minute cycle we stopped to see if there were signs of life or a rhythm on the monitor that could respond to a shock from the defibrillator.
Neither occurred and after 20 minutes it became very clear that Bill wasn’t going to make it. When we agreed to stop, I knew it would be my job to break the bad news to his daughter.
As I walked into the relatives’ room, Sian was sitting holding Clara’s hand, a cup of tea in front of each of them. Bill’s daughter was distraught when I told her the news; as she collapsed in floods of tears, Sian put an arm around her shoulders. Clara thanked us for everything we had tried to do for her dad and I went back out to write up my notes and see some more patients. It was another hour before I walked past the relatives’ room again and to my surprise Sian was still in there with Clara. They were talking and I could see that they’d had at least two further cups of tea.
When my shift ended at 9 p.m., Sian was only just leaving too.
‘I’m so sorry you’ve finished so late, Sian. If I hadn’t called you in to help me with the cannula, you wouldn’t be going home three hours late.’
‘Clara asked me to stay. Her brother lived a long way away and was stuck in traffic coming over. She didn’t want to be on her own, so I promised that I wouldn’t leave her until he got here.’
‘Won’t your daughter be upset with you?’
‘Yes, but she’s used to it by now. It goes with the territory if your mum’s a nurse.’
‘Will you at least be able to claim some overtime?’
‘Fat chance,’ Sian snorted. ‘The managers would just crucify me for working too many hours and breaking the health and safety rules. Clara really appreciated the time I spent with her and that’s enough for me.’
Nurses II
Personally, I think nurses like Sian are among the unsung heroes of this country. An average salary for a UK nurse is around £24,000 per year, which is less money than some Premier League footballers earn in a day. Despite this, nurses are regularly demonised by the media and government alike.
Further Confessions of a GP (The Confessions Series) Page 15