by Adam Kay
The healthcare assistant points out that the empty bottle he was about to throw away is sugar-free orange squash – about as much use in this situation as a book token. I don’t know whether to laugh or cry, but am too tired to do either. A couple of nursing desk Ferrero Rochers later and the patient is feeling much better. The nurse in charge apologizes for an ‘ordering error’ and promises they’ll stock the right kind in future. Two quid says next time I see a hypoglycaemic patient they nip off to the fridge and return holding a butternut squash.
* GCS, or Glasgow Coma Scale, is a measure of conscious level. You get a mark from 1–4 for eye response, 1–5 for verbal response and 1–6 for motor response, giving you a maximum total score of 15 if completely normal and a lowest possible score of 3 if you’re dead. (Or a score of 2 if you’re dead and have no eyes.) For some reason, as if doctors’ lives aren’t hard enough already, patients – particularly in A&E – seem to enjoy pretending that they’re more unconscious than they actually are. In this situation, the textbooks teach applying a painful stimulus to assess if they’re faking it, such as pressing hard on a fingernail or rubbing your knuckles on their breastbone. My preferred method was always to raise one of their arms up and drop it onto their face. If they’re faking, they don’t let their arm plomp onto their face and it miraculously floats off to one side. The downside is if they’re genuinely unconscious and you have to explain yourself to their relatives.
Sunday, 25 December 2005
Good news/Bad news.
Good news: it’s Christmas morning.*
Bad news: I have to work on labour ward.
Worse news: my phone goes off. It’s my registrar. I didn’t set my alarm and now they’re wondering where the hell I am.
Even worse news: I’m asleep in my car. It takes me a while to establish where I am or why.
Good news: it seems I fell asleep after my shift last night and I’m already at work, in the hospital car park.
I leap out of the car, grab a quick shower and then I’m good to go, a mere ten minutes late. I have eight missed calls from H and a text saying ‘Merry Christmas’, full stop, no kiss.
This year we’re doing Christmas on my next day off: the sixth of January. ‘Just think how reduced the crackers will be by then!’ was the only positive I could offer.
* In the NHS, it’s irrelevant that you worked the Christmas before, firstly because that was almost certainly in a different hospital and, secondly, nobody gives the tiniest toss. There’s a pecking order of those least likely to work at Christmas: first up is the doctor who organizes the rota, followed by those with kids. Several rungs further down this hierarchy came me, my childlessness lumbering me with Christmas shifts practically every year. Despite no great paternal yearnings (a feeling exacerbated by working on labour ward), I seriously considered pretending to have children when I started a new job.
Wednesday, 18 January 2006
There are days when you get firm confirmation of your place in the hospital hierarchy, and today’s leveller was a cord prolapse.*
I clamber onto the mattress behind the patient and assume the veterinary position, and the bed gets wheeled through to theatre. Another caesarean is just finishing off, so we wait in the anaesthetic room for the time being. To keep the patient calm and make the situation seem less weird, we have a mundane chat about baby names, nappies and maternity leave.
Her partner had nipped to the cafe downstairs for a few minutes just before things got this . . . intimate, so he missed all the drama. On his return, the midwife quickly brings him up to speed and gets him changed into scrubs so he can come to theatre for the caesarean. She leads him into the anaesthetic room, where I’m kneeling, the vulva of the mother of his child halfway up my forearm. ‘Jesus Christ!’ he says, in a heavy Glasgow accent. The midwife remonstrates that she’d warned him I’d be holding the cord out of the way. ‘You did,’ he says, his eyes like dinner plates. ‘You didn’t say he’d be wearing her like Sooty though.’
* Cord prolapse means that a loop or two of umbilical cord comes out through the vagina during labour, and unless this is right at the point of delivery, it means a very urgent caesarean. Fair enough that the cord got a little caught up in the moment and couldn’t wait to make an appearance, like a firework exploding on the fourth of November, but if it gets cold it goes into spasm, meaning there’ll be no blood going to baby. So, it needs to be popped back into the vagina, and to keep pressure off the cord, the mother has to go up on all fours, resting on her knees and elbows, with the doctor standing behind until the moment she gets laid on her back for the caesarean. The doctor wears a very long glove that goes right up to the shoulder and is revoltingly called ‘The Gauntlet’.
Tuesday, 24 January 2006
God has had the good sense to stay the hell away from my job, aside from a few ‘Holy fuck’s and the odd ‘Jesus!’. Today I meet MM, a Jehovah’s Witness, to consent her for an open myomectomy.* It’s a bloody type of operation, and we should have four units of crossmatched blood in the theatre fridge on standby.
The snag is, of course, that Jehovah’s Witnesses refuse any blood transfusions because of their (fucking stupid) belief that blood contains the soul, and you shouldn’t put someone else’s soul into you. Nonetheless, it’s a free country – so we respect everyone’s (fucking stupid) values and wishes.
MM is bright, charming and erudite, and we have a very interesting discussion. She agrees to have cell salvage† performed during the operation and I give her the specific consent form for refusing blood transfusion, even if needed to save her life. A small possibility but a real one, even with cell salvage – numerous Jehovah’s Witnesses have died because they declined blood products. She signs, though admits part of the reason is that her family would never speak to her again if she received blood. (Even more of an incentive to have a transfusion if you ask me.)
Mr Flitwick, my consultant, tells me that in his sepiatinted, gung-ho version of ‘the good old days’ they’d just ignore the form and plough ahead with a blood transfusion regardless, if needed – the patient would never find out as they’d be under anaesthetic. Happily, today’s operation is gloriously uneventful and the cell salvage machine stays in the corner of the room. I review her back on the ward in the evening and on leafing through her notes I see that her birthday is in two days’ time and she’ll most likely still be in hospital. I commiserate, despite the fact that I, too, will very likely be in a hospital for every single one of my birthdays until I’m too weak to blow out the candles, but she tells me that Jehovah’s Witnesses don’t celebrate birthdays or even receive presents. This is even more fucked-up than the whole blood thing.
* A myomectomy is the removal of fibroids – benign swirls of growth in the muscle of the uterus that you remove using what is essentially a corkscrew.
† Cell salvage involves hoovering up any blood that’s lost during the operation, rather than swabbing it away, then running it through a machine that filters out any impurities (water used during the procedure, surgeon’s sweat, bits of paint that have flaked off the ceiling). Should there be any need for a transfusion, the patient’s own blood can be returned to them – and some Witnesses are happy this is in accordance with their teachings, as the blood stays within a closed circuit and isn’t thought to have truly left the body. I know.
Thursday, 26 January 2006
Moral maze. On the ward round, Ernie is talking to a very well-spoken woman in her thirties – basically a younger, posher version of the Queen. She’s now ready to go home, after an emergency admission a few days ago with ovarian torsion.* He books her in for review in outpatients in six weeks and tells her not to drive for three weeks. ‘Oh, for heaven’s sake!’ she says to Ernie. ‘The bloody thing’s in the car park here. Why don’t you just drive it until I see you in clinic?’ Ernie is about to say no, that’s insane, until she complicates matters by pulling a set of Bentley keys from her handbag. Anyway, Ernie currently drives a Bentley Continental GT.
Friday, 27 January 2006
I’ve been visiting Baby L on SCBU* for three months now – it’s become part of my routine before I head home, and it’s nice to see a familiar face, even if it’s through the glass of an incubator wall.† His mum was admitted on my second Saturday in the job, twenty-six weeks into her first pregnancy, with a blistering headache that it quickly transpired was severe early onset pre-eclampsia.‡ She was stabilized and we delivered Baby L on the Sunday; I assisted the consultant in the section. Mum ended up spending a few days in intensive care – so we definitely couldn’t have waited any longer before delivering – and baby came out a tiny scrap of a thing, weighing in at just over a jar of jam.
Neonatologists make obstetricians look like orthopaedic surgeons – they’re so academic, so meticulous – defying God and nature to make these babies pull through. As recently as 1970, this baby would have had chances of survival under 10 per cent, but today the odds are over 90 per cent. After twelve weeks of neonatal magic he’s gone from a transparent-skinned shrew attached to a dozen tubes and wires to a proper screaming, vomiting, sleeping little baby, and he’s getting discharged home this afternoon.
I should be delighted he’s going home – and I am, of course, that’s our entire raison d’être – but I’m going to miss seeing my little pal every couple of days.
I buy the least ghastly card they have in the League of Friends shop and leave it with the paediatric nurses to pass on to his mum. I say how pleased I am their story had a happy ending, give her my phone number and ask her to maybe text me a picture of him every so often. Yes, it’s probably against GMC regulations and hospital protocol and contravenes all sorts of small print, guidelines and best practice, but I’m prepared to go down for this one.§
* SCBU (pronounced Scaboo) is the Special Care Baby Unit, NICU is Neonatal Intensive Care, PICU is Paediatric Intensive Care, PIKACHU is a type of Pokémon.
† Something very unsatisfying about house-officer jobs was the way you never found out the end of the story – every patient’s box set was missing the final DVD. A patient would come in with pneumonia, you’d get him well enough to go home, and then he’s gone – he could live another fifteen years, die on the bus home or anything in between and you’d almost certainly never know. Extreme nosiness aside, it always felt like it might have been useful to find out if our management plans were any use. I liked that obstetrics played out much quicker – you would get to watch right through to the credits; and by reflecting back on your decisions in the context of these outcomes, you could learn and improve as a doctor. And so, if a baby went to SCBU, I made a point of popping by to see how they were doing.
‡ Pre-eclampsia is a disorder of pregnancy which can affect most organs of the mum’s body, causing liver and kidney damage, swelling of the brain, fluid in the lungs and platelet problems, as well as problems with baby’s growth and well-being. It ultimately progresses to eclampsia – life-threatening fits. Most cases of pre-eclampsia are mild, but every pregnant patient has their blood pressure and urine protein measured at each visit, in order to pick up the condition at an early stage. The only cure for pre-eclampsia is delivering the placenta (and necessarily the baby first). For the vast majority of pre-eclamptic patients, they’ll end up just being monitored throughout pregnancy, taking some tablets to reduce their blood pressure or having labour induced a week or two early. Some patients, however, develop the condition severely and much earlier in pregnancy, leading to the painful decision to deliver the baby prematurely, to prevent terrible consequences for both mother and child.
§ And she did text me.
Thursday, 2 February 2006
Signing letters to GPs in the gynae office.
Dear Doctor,
I saw XA in clinic with her husband Sam, Esther Sugar and their two children . . .
A moment while I try to remember the appointment. Who of these three were the children’s parents? I feel I should know who Esther is – why the full name? Is she famous? Wife of Sir Alan? As it turns out, Esther wasn’t there at all.
Two months ago, the trust laid off almost all the hospital secretaries, replacing them with a new computer system. The first key difference is that rather than giving your Dictaphone tapes to the secretaries, you now dictate straight onto your clinic computer, which chooses to either upload your audio and send it abroad to the secretarial equivalent of a sweatshop or to instantly delete it without trace. The second key difference is that the quality of the transcription would suggest the backend of the system involves two tin cans, a length of string and a lemur who’s been trained to type. We’re not to worry about that though: the main thing is all the money the trust is saving by sacking so many long-serving, hardworking members of staff who adored the hospital. The one advantage of this system is that you can listen back to your original audio when reviewing documents. I press play.
‘Dear Doctor,
I saw XA in clinic with her husband Sam (S for sugar) and their two children.’
I’m confident this takes me to the top of the leader board in departmental dictation fuck-ups, unseating ‘The patient has known analogies’ (no known allergies).
Wednesday, 22 March 2006
Three a.m. attendance at labour ward triage. Patient RO is twenty-five years old and thirty weeks into her first pregnancy. She complains of a large number of painless spots on her tongue. Diagnosis: taste buds.
Monday, 3 April 2006
It’s 2 a.m. and there’s not much doing on labour ward so I slope off to the on-call room to catch up on some personal admin (Adamin?) and stare at Facebook for a bit. I comment on how cute a friend’s latest ugly baby looks, which I can do very convincingly as I spend a large proportion of my working day doing the same thing to total strangers. For me, the true miracle of childbirth is that smart, rational people with jobs and the ability to vote look at these half-melted fleshy blobs, their heads misshapen from being squeezed through a pelvis, covered in five types of horrendous gunk, looking like they’ve spent a good two hours rolling around on top of a deep-pan pizza, and honestly believe they look beautiful. It’s Darwinism in action, an irrational love for your progeny. The same hardwired desire to keep the species going that sees them come back to labour ward for round two, eighteen months after the irreparable destruction of their perineum.
The other miracle of childbirth is that I can put metal forceps on a baby’s head and lean backwards – applying 20 kg of traction force on it, generally getting a sweat on – and the baby comes out absolutely fine, rather than, as you might expect, decapitated. Once it’s born, every new mother obsesses over keeping the head straight with a cradled hand. If photographs could talk, ‘Careful of his neck!’ is the shriek you’d hear over any picture of a childless relative posing with a newborn. But I’m pretty sure you could carry it by its head and it’d be totally OK.*
I’m just going through exes’ profiles to check they’re colossally miserable and overweight without me when I see a post pop up from Simon, a school friend’s younger brother. He’s twenty-two and even though I’ve only spoken to him twice, a decade ago, this is Facebook, where everyone’s your friend. It’s simple and devastatingly effective. Four words: ‘Goodbye everyone. I’m done.’
I realize I’m probably the only person to be reading this at 2.30 a.m. on a Monday, so I send him a private message to ask if he’s OK. I say I’m awake, remind him I’m a doctor and give him my mobile number. I’m scrolling through my phone to see if I have his brother’s number, when Simon rings. He’s an absolute mess: drunk, crying. He’s just split up with his girlfriend.
I’m actually no better trained to counsel him than I would be to talk him through replacing a gearbox or laying a parquet floor, but he assumes I am, and that’s good
enough for both of us. Two (miraculously bleep-free) hours later and we’ve had a good chat. He’s going to get a cab to his mum’s then make an emergency appointment with his GP in the morning. I feel the same weird endorphin rush as after dealing with any medical emergency – exhaustion plus exhilaration and the vague feeling of having done a ‘good thing’ (like how you’d feel after running a 10k for charity). It’s likely I’ve made a bigger difference to Simon than any of my patients tonight.
I answer a bleep and head to labour ward to review a woman at thirty weeks who decided she needed her eczema seen at 5 a.m. ‘I thought it would be quieter now than in the morning,’ she says.
* This is not medical advice.
Monday, 10 April 2006
Referral from an A&E SHO – patient has some kind of warty vulval growth. I ask him if he can describe it a bit more. ‘Like cauliflower florets, mate. Actually, what with the discharge, it’s more like broccoli.’
H did not enjoy this story over dinner.
Friday, 21 April 2006
Ron is having a minor knee op next week and wants me to reassure him that he’s not going to die during the anaesthetic, reassurance that I’m underqualified yet perfectly happy to give him.
He also asks if sometimes the anaesthetic ‘doesn’t work’, so I tell him a story from earlier this year at work:
‘So, there are two main drugs that anaesthetists give. Firstly, a muscle relaxant – so that the surgeon can have a proper fiddle around. With the body completely paralysed, you can’t breathe unassisted, which is why you get hooked up to a ventilator during the procedure. The second drug’s a cloudy fluid called propofol, which makes you unconscious, so you’re asleep throughout the procedure.*