This is Going to Hurt

by Adam Kay

  Monday, 6 April 2009

  Eyes down for an elective caesarean section – this time for placenta praevia.* In the event, a very straightforward one, but everyone is quiet and focused in case it gets messy. Everyone, that is, except the dad, who is determined to engage me in pitiful banter.

  ‘Whoa, I’m glad she’s got skin covering that the rest of the time’, ‘This must put you off women, doc’, something about the baby’s penis and the umbilical cord – all the classics. I presume it’s just because he’s nervous, but it’s extremely irritating and distracting, and none of his lines would even make it onto the speech bubble of a saucy seaside postcard. I ‘mm-hm’ at his zingers, and all but say, ‘I’m really trying to concentrate here. Let me deliver this baby. I didn’t rock up at the conception and distract you from your pumping with my pound-shop repartee.’

  He continues. ‘Better not come out black, eh? Ever had a baby come out a different colour to the parents?’

  ‘Does blue count?’ I offer. Banter over.

  * Placenta praevia is a placenta that is attached at the lower part of the uterus. The implications of this are that the baby needs to be delivered by caesarean because the placenta’s in the way for delivering vaginally. It also means that if mum goes into labour, it’s a bit of an emergency as the placenta is liable to shear off, with profound consequences for both baby and mother (700 ml of blood goes through the placenta every minute – her entire blood volume in five minutes).

  Friday, 17 April 2009

  Patient JS is twenty-two years old and has presented to A&E with acute abdominal pain. The A&E officer tells me she’s had a negative pregnancy test and has been reviewed by the surgeons, who suspect it’s probably a gynae issue. I review her. She looks reasonably well – pulse a bit high, tummy a bit tender, but walking and talking easily. Admitting her to the ward would be overkill, and sending her home would probably be underkill. If this was a daytime shift during the week I’d probably just squeeze her onto someone’s ultrasound list to check there’s nothing sinister going on. But it’s a Saturday night and the NHS runs a skeleton service. Actually, that’s unfair on skeletons – it’s more like when they dig up remains of Neolithic Man and reconstruct what he might have looked like from a piece of clavicle and a thumb joint.

  One would generally err on the side of caution and admit her until she can be scanned in the morning, wasting a night of the patient’s life rather than sacrificing my career if I’ve called it wrong. It also wastes the cost of a hospital bed, which is around the £400 mark. I suspect the cost of an ultrasonography shift would be considerably lower than this, and you’d save at least one such admission a night, but who am I to tell the hospital how to spend its money? Particularly when they’ve just decided to get rid of the beds from our on-call rooms. (Perhaps they’ll save money on the bed linen they remember to change every week or two? Perhaps they were worried morale was running a little too high? That doctors would be too alert, too on it, if they got some sleep?)

  We’re OK in obs and gynae – the Early Pregnancy Assessment Unit sister took pity on us, no doubt clocking the size of the bags under our eyes, and had a spare key cut so we can kip on a hospital bed in her unit. It’s an act of charity so kind and so rare that it made my colleague Fleur cry, and then scour the honours website trying to work out if Sister would be eligible for an OBE. It’s hard to describe the joy of hearing you’ll have a bed to lie in, after a few night shifts spent trying to snatch some sleep in an office chair. It’s a bed with stirrups, but beggars can’t be choosers; I’d have accepted a bed with a grand piano dangling from the ceiling above it by a single pube if there was any chance of some shuteye.

  I suddenly realize it’s also a bed with an ultrasound machine sat next to it. I check JS is still good to walk, and take her off upstairs – if all looks well on a quick scan she can head home, and I won’t even bill the NHS the £400 I’ve saved them through my ingenuity.

  In retrospect, it was a mistake to not tell the A&E sister I was borrowing the patient. I imagined being informed of some bit of protocol that meant I wouldn’t be allowed to, and nobody’s got time for that kind of argument. It was also a mistake not to book a porter to take her up with me in a wheelchair. But the biggest mistake of all was definitely made by the A&E officer who told me the patient had had a negative pregnancy test – unless ‘negative pregnancy test’ is the rather confusing term he uses for ‘I have not performed a pregnancy test’.

  By the time we’ve gone upstairs, through a depressing lab-rat maze of corridors and into my makeshift bedroom with en-suite ultrasound machine, JS is looking a little peaky and a lot out of breath. Ultrasound of her abdomen shows a ruptured ectopic pregnancy, her belly swimming with blood. Instead of being where she should be, in close proximity to life-saving equipment, she’s kicking back with me in a closed-off part of the hospital, like we’re two teenagers who’ve slunk off for a snog.

  Half an hour of panicked phone calls later, we’re in theatre, JS is a few bags of blood better off, a fallopian tube worse off, and will be absolutely fine. I have no idea what the moral of this story is.

  Sunday, 26 April 2009

  Called to review a patient in A&E. According to her notes she is aged thirty-five and employed in a massage parlour, in a capacity one suspects doesn’t involve a whole lot of massaging – at least not with her hands. She presents with a lost object in her vagina. A busy shift, so no time for too many questions, and it’s legs up, lights on, speculum in, see it, grab it, remove it. Without doubt, this is the worst smell I’ve ever experienced. Truly indescribable – other than to say that I retch, and the nurse chaperone has to immediately leave the cubicle. I imagine every bunch of flowers in the hospital suddenly wilted. I hardly want to ask, but I need to know the culprit.

  The short answer is it was the head of a Fireman Sam bath sponge. But of course! The long answer is she realized a number of months ago her income was being seriously compromised because there were certain dates of the month when her clients didn’t want to be ‘massaged’ – so she created an impromptu menstrual barrier device by decapitating Samuel. Christ knows how she explained the change in his appearance to her children – did any of them notice? Were they worried they’d be for the guillotine next if they asked as to its whereabouts? While effective at soaking up menstrual blood from above, and quite noticeably effective at absorbing other fluids from below, Sam’s bonce-barrier didn’t have a string to facilitate its removal. Plus it had been schnitzeled flat by her clients’ pummellings over the past three months.

  Actually, it’s unfair to say the smell was indescribable – it’s describable as three months of menstrual blood mixed with vaginal secretions and the fetid semen of assorted men, the number of whom must have run into three figures. While prescribing her some antibiotics, I let her know that no further novelty sponges needed to be executed in her honour – she can also stop her periods by the more traditional method of taking the oral contraceptive pill back to back. I leave it to A&E to decide how to label the item within the microbiology sample pot.

  Monday, 4 May 2009

  Another day, another emergency buzzer or twelve. I go to perform a ventouse extraction for a non-reassuring trace, but as I’m about to Dyson the little bastard out of there the trace improves so I take my gloves off and hand back over to the midwife for a normal delivery. I loiter at the back of the room to keep an eye on the trace in case it misbehaves again, but all is well and soon baby’s head is crowning.

  Dad is down the business end, witnessing the miracle of childbirth for the first time – awwing, cooing and excitedly telling his wife how brilliantly she’s doing. The midwife tells mum to stop pushing and start panting, so she can guide baby’s head out slowly and hopefully avoid too much of a tear. As the head advances, dad screams, ‘Oh my God – where’s its face?!’ Mum understandably also screams, her baby’s head shoots out uncontrolled and her perineum explodes. I explain to them that babies are generally born facing downward
s,* and their baby’s face looks perfect (if slightly more blood-splattered than it might have been). I put some gloves on and open a suture set.

  * Only 5 per cent of babies are born looking upwards – the medical term for which is ‘occipito-posterior’. The cutesy-wutesy term is ‘star-gazing’, the old-fashioned term is ‘face to pubis’, and the term I misheard as a junior SHO and then mortifyingly used for a year, until I was corrected by a colleague, is ‘face to pubes’.

  Tuesday, 5 May 2009

  Patient in antenatal clinic requests a caesarean section without a clinical indication. I explain our unit doesn’t perform caesareans on request: there needs to be a medical reason, because it’s an operation, with attendant risks of bleeding, infection, anaesthetic and so on. Her argument was she didn’t want to go through a long labour and then end up with an emergency caesarean. I was obviously bang to rights – a planned section is much safer than an emergency one, and generally safer than an instrumental delivery too – but couldn’t say so.

  She wasn’t done trying. ‘Aabaat fimetoo poshtapush?’ she said in her finest estuary drawl, which I eventually decoded as ‘How about if I’m too posh to push?’ I felt mean saying no, especially as a third of female obstetricians elect for caesareans – it’s clearly not fair.

  I was on the other side of the fence yesterday. H and I were looking to upsize mildly and were going round a flat we liked with an estate agent. The barely twenty-year-old weasel was doing the hard sell; it’s a great location, we were told – he bought his own place on the road behind. This made it all the more depressing; an embryo in shiny nylon could spare the cash to buy a flat somewhere we can barely afford. Was I in the wrong job? Or is an estate agency like a charity shop, where the staff get first dibs on everything that comes in?

  He told us the sellers of this place had previously rejected a below-asking-price offer, but he couldn’t tell me how far below asking price – it’s against estate agents’ weasel-law, a code of honour among the dishonourable. I asked him if his colleagues tipped himthe wink about how far below asking price any other offers were when he was buying his own flat. He went a delightful shade of sun-dried tomato. ‘Ask me my favourite number of pounds!’ he said. Turns out his favourite number was 11,500.

  ‘Ask me why some women have caesareans,’ I said to the patient. I waited for her intellectual satellite delay to catch up, and she asked. I answered that some women are worried about the significantly worse long-term effects of normal deliveries on bladder and bowel continence, as it would markedly affect their lifestyle. Turns out she was too, and is now booked in for an elective caesarean at thirty-nine weeks.

  Thursday, 25 June 2009

  Down in A&E around 11 p.m. to review a patient, and thumbing through Twitter while I work up the strength to see her. There’s a big news story breaking, but so far only gossip-merchants TMZ have reported it. ‘Oh Christ,’ I gasp. ‘Michael Jackson’s dead!’ One of the nurses sighs and stands up. ‘Which cubicle?’

  Saturday, 18 July 2009

  If they’re updating the Hippocratic oath any time soon, they should add in a line about never mentioning you’re a doctor at parties. Particularly for obs and gynae staff, where it opens up an entire hell-mouth of discussion with every woman on the planet – questions about contraception or fertility or pregnancy. I’ve become extremely good at being vague about what I do when I meet new people, or magically changing the subject.

  At a house party tonight, conversation turns to the niqab, and someone chips in that underneath their niqabs a lot of women wear very high-end fashion, often thousands of pounds of clothing hidden from view. ‘It’s true,’ I say. ‘And underneath that I’ve seen so many orthodox Muslim women with Agent Provocateur lingerie, and half a dozen with really elaborate pubic topiary. Initials shaved in, spirals, the lot!’ Absolute silence. Then I realize that I’ve overdone it on the mystery. ‘I’m a doctor by the way.’

  Tuesday, 28 July 2009

  Booking a couple in for an elective caesarean and they ask me if there’s any chance they could choose a particular date. They’re a British Chinese couple, and I know that according to the Chinese zodiac, certain days of the year are lucky or unlucky, and it’s of course preferable to deliver on an ‘auspicious date’, as it’s known.

  Obviously we’ll try our best to accommodate this, if safe and practicable. They ask me to check for the first or second of September. ‘Auspicious dates?’ I ask, smiling and mentally clearing a space on my lapel for an ‘excellence in cultural sensitivity’ badge.

  ‘No,’ the husband replies. ‘September babies go into a different school year and perform better in exams.’

  Monday, 10 August 2009

  Yes, madam, you will shit during labour. Yes, it’s completely normal. It’s a pressure thing. No, there’s nothing I can do to stop it. Although if you’d asked me yesterday I’d have suggested that the massive curry you ate to ‘induce labour’* probably wasn’t going to help matters.

  * Curry can’t induce labour. Nor can pineapple. Nor can sex. There is no scientific evidence whatsoever for these three perennial old wives’ tales. I presume they were dreamt up by the inventor of the pineapple madras when he was horny.

  Monday, 17 August 2009

  Teaching the medical students a bit of pelvic anatomy when someone from med school administration appears with news of Justin, the missing member of the group. He won’t be joining us for the rest of the term, and it sounds very much like he won’t be joining the medical profession at all. Last night, he got into a fist fight with his boyfriend at a nightclub and the police were called. The police spotted that Justin had a quantity of white powder on him; they suspected it wasn’t Canderel and arrested him on the spot. Justin’s defence was that he should be immediately released on the basis that he’s a medical student and his country needs him. This backfired ever so slightly and the police contacted the medical school, accounting for his absence this morning.

  The administrator leaves and no one’s particularly interested in learning pelvic anatomy any more (if they ever were). We have a discussion about fitness to practise among medical students and getting struck off before you even get struck on. Every single student asks at least one gossamer thinly veiled ‘What if a student did this?’ hypothetical question, before each of their faces drains of colour on hearing my answer. I regale them with the story of some contemporaries of mine who got sent down. A bunch of third years were on a rugby tour in France; a tour that consisted of the odd game of rugby and countless hours of drinking games. The most inventive of these games involved visiting local hostelries and making ‘Very Bloody Marys’. They would order large measures of vodka from the bar, return to their tables, produce needles and syringes, venesect each other, squirt blood into each other’s vodkas and then neck them. The gendarmerie point-blank ignored the rule of ‘what goes on tour stays on tour’ and responded quite urgently to the bar staff’s concerns about all the discarded needles on their premises, arresting the students and informing the university. My tutorial group seemed happy that this was a striking-off offence, although one raised the mitigating factor that it’s pretty impressive for a group of third years to be able to take blood.

  ‘Poor Justin’ still seemed to be the prevailing feeling amongst them. My suggested ‘Poor Justin’s beaten-up boyfriend’ fell on fairly deaf ears.

  ‘I just can’t believe it,’ one girl sighed loudly. ‘Justin’s gay?’

  Wednesday, 19 August 2009

  Moral maze. Working my way through the day’s elective caesareans. This one is for breech presentation – I cut through the uterus and the baby quite clearly isn’t breech. Fuck. I should have scanned the baby before I started – you’re always meant to, just in case the baby has turned since the last ultrasound. Which it never has. Except today.

  My choices are as follows:

  a) Deliver the magical revolving baby and confess to the patient I’ve done a completely unnecessary caesarean section, scarred her abdo
men and confined her to hospital for a few days, when she could have had a normal delivery.

  b) Deliver the baby and pretend it was breech – this would involve lying in the notes, and persuading my assistant and scrub nurse to perjure themselves by colluding.

  c) Stick my hand inside the uterus, rotate the baby, grab a leg and deliver it breech.

  I choose a) and fess up to the remarkably understanding patient, who I suspect actually wanted a caesarean in any case. Then it’s time to fill in the clinical incident form and tell Mr Cadogan. He’s very nice about it and says at least I’ll never forget to scan a patient before a section again.

  He also makes me feel much better by telling me about an unnecessary section he once performed as a junior trainee. Baby wasn’t coming out with forceps, so he performed an emergency caesarean. Unfortunately, when he got inside the abdomen, the baby had somehow delivered vaginally in the meantime.

  ‘How did you explain that to the patient?!’ I ask.

  There’s a pause. ‘Well, we weren’t always quite so honest with the punters back then.’

  Thursday, 20 August 2009

  I consent patient YS for Termination of Pregnancy – an unplanned, unwanted pregnancy in a twenty-year-old student following condom failure. We discuss alternative methods of contraception and correct condom usage.* I identify an error in her technique. I’m as big a fan of recycling as the next man, but if you turn a used condom inside out and put it back on for round two, it’s probably not going to be that effective.†

  * I performed a large number of TOPs in this job, as a lot of the other junior doctors had objections for ethical or religious reasons (or pretended to, because they’re work-shy bastards). No one’s first choice of a way to spend a morning, but a necessary evil, and as a result I developed excellent surgical technique for ERPC – the near-identical surgical procedure required following certain miscarriages. By now I could probably hoover the stairs through my letter box if needed. This patient didn’t want to raise a child, and we live in a civilized society – it’s not fair on her or the child to force her to go through with it, as some of our near neighbours should note. According to the letter of the law (the 1967 Abortion Act to be precise), two doctors need to agree that continuing with a pregnancy would be damaging to the patient’s mental health, but in reality that covers any unwanted pregnancy. In this case the patient had attempted to take reasonable precautions against falling pregnant. Used correctly, condoms can be 98 per cent effective, but frequent mistakes include late application, early removal and incorrect lubrication, so it’s always good to check they’re being used properly.