This is Going to Hurt

by Adam Kay

  He would definitely faint, vomit or both at what it looks like inside an abdomen: a casserole of flesh and giblets cooked up by someone irrevocably insane. Besides, it takes most trainees a good few sections before they can get a baby out by the head – unless he can quickly practise by scooping cantaloupe melons out of a swamp one-handed? Plus no one seems to realize there’s a whole tricky ritual that takes time to learn, namely getting scrubbed and then into gown and gloves. Gloves! ‘How about if we pass baby straight to you?’ I suggest. ‘We’ll be wearing gloves so you’ll be the first person to actually touch her.’

  Sold.

  Thursday, 25 February 2010

  The emergency buzzer goes off in labour ward. The whole team runs down the corridor and none of us can see a room with a flashing light outside.

  You’d think they might come up with a more high-tech system given lives are at stake, but we’re stuck with the aeroplane passenger call set-up. One person presses a button, the entire place hears a piercing beep every couple of seconds, and then the cabin crew/obstetric team has to traipse up and down looking for a light, until they find whoever pressed it and can turn the noise off. If only I could swap medical emergencies for something as serene as refilling someone’s G&T or a terrorist saying he’s going to blow up the plane.

  The alarm is still going and, with precious time draining away, we decide to go from room to room, checking in on every single labouring patient. Clearly one of the lights has broken.

  No one seems to be having an emergency. Where else is there? Changing rooms, labour ward theatres, toilets, anaesthetic rooms, tea room – we split up like Scooby Doo and the gang to cover every inch of the ward. Nothing. A literal false alarm. Aside from the fact it’s deafeningly loud, every single member of staff is conditioned to react to this sound by leaping into action. It’s too unsettling for background noise, much like if the radio started playing an air-raid siren.

  We call engineering. Some bloke comes up and fucks around uselessly with a box on the wall for ten minutes. They’ll get someone over to fix it tomorrow, apparently – until then we have the choice of a constantly blaring alarm or no alarm system at all. We summon Prof Carrow, the on-call consultant, and he’s furious. Mostly because he’s spent the last decade successfully avoiding walking onto labour ward during his shifts, and also – as he points out to the engineer – this counts as an extremely serious clinical incident. Lives are being endangered and the company needs to come out immediately to resolve it. The engineer mutters he’ll do his best, but no promises – and besides, what happened on labour wards a hundred years ago, before emergency buzzers?

  Prof Carrow fixes him with a zero-degree Kelvin glare. ‘One in twenty women died in childbirth.’

  Wednesday, 3 March 2010

  Putting in the last of the skin staples after an uncomplicated elective caesarean when the scrub nurse announces there’s a discrepancy in the swab count – one’s unaccounted for.* Don’t panic, we tell ourselves, panicking. We check on the floor and inside the drapes – no swab. We rifle through the placenta and blood clots in the clinical waste bin like the world’s most horrific bran tub – no swab. I call in Mr Fortescue, today’s on-call consultant, to make the decision as to whether we re-open the patient or send her for an X-ray.†

  Mr Fortescue decides we should re-open, and we wait for the anaesthetist’s epidural top-up to take effect. He tells me a story from a few years ago: an elderly woman presented to him in clinic complaining of lower abdominal pain. After performing various other investigations, he sent her for an X-ray. The principal finding was the presence of a spoon in her abdominal cavity. After asking various pertinent questions – ‘Have you ever eaten a spoon?’, ‘Do you stick spoons up your vagina or rectum?’ – it seemed unlikely the origin of the object would be discovered. But it was causing her pain and needed to be removed at open surgery, under general anaesthetic.

  Sure enough, at surgery, nestled among her intestines and other gizzards, was a dessert spoon. On removal, its only notable features were a number of scratches on the rear surface and the words ‘Property of St Theodore’s Hospital’ stamped onto the handle. Mr Fortescue saw her on the ward post-operatively and they were each equally baffled as to how the spoon had somehow managed to backpack its way from St Theodore’s into her abdominal cavity. Her last contact with them, save for their spoon stirring her innards like a risotto, was a caesarean section back in the 1960s. Some correspondence with St Theodore’s followed, where they firmly denied the routine surgical implantation of spoons, but were able to dig out the patient’s notes. They were unrevealing, spoon-wise – it seems very few doctors who empty canteens of cutlery into patients’ stomachs are going to document it – but did provide the name of the surgeon. The gentleman was long since dead, but Mr Fortescue was eventually able to speak to someone who trained under him, to ask if his old boss was in the habit of breaking mid-caesarean for a spot of baked Alaska. Amazingly, this revealed the explanation. The surgeon in question routinely used a sterilized dessert spoon when sewing up the rectus sheath,‡ to protect underlying structures. On this occasion the spoon had clearly fallen in, and he’d just decided ‘sod it’ and ploughed on.

  Our anaesthetist calls over that we’re good to proceed, and as I start to remove the skin staples a midwife runs into theatre telling us to stop because the swab has been found: the baby was holding it. Much relief all round, except from the scrub nurse who has been subjected to half an hour of unnecessary stress and binsearching. ‘The thieving little cunt,’ she says – not seeing that directly behind the midwife is the swab in question, held by the baby in question, held by its father.

  * For every operation, an inventoried set of instruments are used – and they are counted meticulously in and out. Swabs are packed together in stacks of five, and at the end of the procedure, the scrub nurse makes sure that she’s discarding a total number of swabs that are a multiple of five so we know that none have been left inside the patient. (Unless five have somehow been left inside the patient.)

  † Swabs are designed with a radio-opaque thread running through them as a marker, which show up on X-rays as a line. A bit unimaginative – I’d have gone for a radio-opaque ‘WHOOPS!’

  ‡ The rectus sheath is a fibrous layer underneath your abs – when you sew it back up you need to be careful not to accidentally nick any of the underlying organs.

  Thursday, 18 March 2010

  A&E bleep urgently – a woman is delivering a baby at twenty-five weeks in a cubicle. Myself, SHO, anaesthetist and midwife peg it down to A&E, with the neonatal team following shortly behind, wheeling all their gubbins. She’s huffing and puffing and in a terrible state – the anaesthetist gives her some pain relief. The midwife can’t pick up a fetal heart with the Sonicaid – not good.

  I examine the patient. She’s not actively delivering. In fact her cervix is long, hard and closed – she’s not in labour at all. This is odd. I ask where she’s booked for this pregnancy and she says it’s here. Someone looks her up on the computer and there’s nothing, not that this is unusual. The computer denies knowledge of almost every patient – we’d be better off with tarot cards.

  One of the A&E staff scrambles to find me an ultrasound machine and I ask the patient when she had her most recent scan. Last week. This hospital, right? Yep. On the fifth floor? Yep. Ah, I see. I send the anaesthetist, midwife and paediatricians away. Any scans for patients here happen on the ground floor of this three-storey hospital.

  The ultrasound machine appears, and luckily, given I’ve just sent away the rest of the team, there’s no baby – just some distended loops of bowel making her look pregnant-ish. If you squint.

  ‘But where’s the baby? Where’s it gone?’ she screams to a packed and no doubt fascinated A&E department. I tell her my colleagues will be along shortly to explain, then ask A&E to contact psychiatry to kindly take over her management. I scoot over to the coffee shop for a sit-down and a quiet reflection on what I’ve just e
xperienced. I’m cross other patients have been potentially endangered by her wolf-cry dragging so many clinicians away from labour ward. I’m baffled as to what she thought was going to happen – she knew she was about to get rumbled, right? And I’m sad for her – what kind of traumas and demons have taken her to a place where she does this? Hopefully my friends in psychiatry are currently giving her the help she needs.

  Shame on me for thinking I’d be able to get through a whole coffee undisturbed. I’m suddenly fast-bleeped to labour ward and run there as quickly as I can.

  ‘Room four!’ shouts the senior midwife as I wheeze onto the ward. It’s the woman from A&E, huffing and puffing away again. She’s clearly not giving up so easily and has absconded from A&E before her psychiatric review to try her luck elsewhere.

  She sees me and looks extremely pissed off, parade well and truly rained upon.

  Saturday 27 March 2010

  A nice evening out with a few old med school friends to persuade ourselves that our lives are fine, despite significant evidence to the contrary. It’s nice to catch up, even if it needed to be rearranged seven times.

  After dinner, we end up at the med school bar for old times’ sake, and then for some reason, perhaps muscle memory from the last time we were there, start playing drinking games. The only game we can all remember the rules to is ‘I have never’. It descends into therapy: all six of us have cried because of work, five of us have cried while at work, all of us have been in situations where we’ve felt unsafe, three of us have had relationships end because of work and all of us have missed major family events. On the plus side, three of us have had sex with nurses, and one of us while at work, so it’s not all bad.

  Monday, 19 April 2010

  Miss Burbage, one of the consultants, has taken two weeks’ compassionate leave because one of her dogs has died. Much piss-taking in the labour ward coffee room. I come to her defence, to everyone’s surprise, not least my own.

  Miss Burbage despises me – she decided I was hateful the moment she met me and hasn’t budged from this standpoint. When I asked if I could get away from clinic early one evening for an anniversary dinner (earlier than it was going to end, not earlier than I was contracted to be there), she told me I should stay, on the grounds that I’d ‘find it easier to get a new partner than a new job’. She told me if I expected to work in diabetic antenatal clinic, where I’d have to speak to patients about their diet, I’d need to have some self-respect and lose some weight (my BMI is 24). She has slapped my hand in theatre for holding a retractor incorrectly, and told me off for blasphemy after I said ‘damn’. She has shouted in front of a patient that I’m an idiot and need to go back to med school.

  And yet I’m sat defending her in front of my colleagues. Why make fun of someone for being upset? Surely this is cause to respect her – she knows everyone will find out her tough exterior was just that, an exterior. Shouldn’t we feel sorry for someone who has so little else in their lives that they can be so totally floored by the death of their pet? Grief is grief – there’s no right way and no normal. Mumblings of ‘maybe’ all round, and I wander off, having thoroughly suffocated that conversation with the pillow of my compassion. Two weeks for a dead dog though – the woman’s fucking nuts.

  Wednesday, 21 April 2010

  One of the medical students saw me after a tutorial and asked me if I wouldn’t mind taking a look at his penis. I did mind, but didn’t really have much choice – it presumably takes quite a lot of nerve to ask one of your teachers to look at your dick. (Except in porn, where it seems to happen fairly regularly.) I took him into a side room and put on some gloves for the illusion of professionalism. He told me his penis was bruised and he’d had trouble urinating since last night.

  It seemed there were certain elements of the story he’d omitted; his cock looked like an aubergine that had been attacked by a tiger – swollen, purple, and with deep oozing gashes down its entire length. On further questioning, I learned he was boasting to his girlfriend last night about the strength of his erections and announced to her that its throbbing robustness could stop the rotary blades of a desk fan. His hypothesis was monumentally incorrect and the desk fan proved the clear winner.

  I suggested he attend A&E – a couple of the wounds needed closing and I suspected he might need catheterization until the swelling died down. And maybe go to a different hospital’s A&E actually unless he fancied being known to his colleagues for the rest of his time here as Cock au Fan.*

  * Or Tony Fancock. Or Knob-in-Fan Persie.

  Thursday, 22 April 2010

  Perform my first cervical cerclage,* under the supervision of Prof Carrow. In pretty much any other procedure, the consultant supervising you can slam his foot on the metaphorical dual controls at any point and stop you doing too much damage. But cerclage is all on you – they can talk you through it, but the tiniest slip with your stitch, anything but the steadiest hand, and you can rupture the membranes and end the pregnancy, doing exactly what the procedure is trying to prevent. And there’s no way to practise the technique at home, like the way we learned to close wounds as house officers by cutting into an orange and sewing it back up.

  Patient SW lost her first pregnancy at twenty weeks and is now thirteen weeks into her second. Prof tells me to take it nice and slow, as steadily as I can. I’m aware that any shaking of my hand is magnified tenfold at the other end of the long needle-holding forceps, up by her cervix. Deep breaths, blink the sweat out of my eyes, one stitch, two, three, four, done. Got away with it.

  I think it’s the first time I’ve changed into a fresh pair of scrubs because my own sweat was the bodily fluid soaking me. It occurs to me scrubs are probably that shade of blue so patients can’t see your sweat marks – a calm and professional demeanour is all well and good until the rapid darkening of your underarms betrays you.

  Later, I realize there actually would be a way to practise the exact kind of small motor skills I need ahead of next time. I text my mum to ask if she by any chance still has that game of ‘Operation’ tucked away in a drawer.

  She replies to say she’s found it. She also has a Magic 8-Ball, she tells me, in case I need it for my diagnoses.

  * Cervical cerclage is the treatment for cervical incompetence – a slightly horrible, cervix-shaming term for when the neck of the womb opens far too early in the pregnancy, causing late miscarriages or very pre-term births. The cerclage stitch is inserted during the first trimester of pregnancy and hopefully holds the cervix shut until just before full term.

  Saturday, 24 April 2010

  Moral maze. Patient AB is in labour and has a non-reassuring trace. She’s on her third midwife of the shift, having hurled racist abuse at the first two (black) midwives who had been looking after her. One more episode like that, she’s been warned, and she’ll be kicked off the labour ward. My SHO has reviewed the CTG and advises me that AB needs a caesarean section. Because I’m not entirely sure of the legality of following through with the threat to boot her out, the Indian SHO and I choose to ignore the fact that the patient has made racist comments to her too.

  On reviewing the patient, I agree with the SHO – c-section it is. I transfer her to theatre and decide to stay tight-lipped about the fact I’m Jewish. The operation is straightforward, and a little boy is delivered safely (presumably to be immediately dressed up in ‘Baby’s First KKK Hood’ and given a rattle in the shape of a burning cross).

  But. If the patient had a dolphin tattoo on her right groin, would it be so bad if my skin incision was slightly wider than usual and I had no choice but to decapitate the dolphin? I could say, if pushed by an official inquiry (or some EDL henchman) that I’d been worried the baby was larger than average and it had made sense to have a good-sized operative field. And on closing the skin, would it be so bad if the wound didn’t approximate very well for some strange, almost certainly unprovable reason, leaving the dolphin’s head positioned a good inch to the left of its body?*

  * We
ll, we’ve spoken to a lawyer and the answer, it turns out, is ‘Yes. That would totally be assault.’ So we’ll say that I didn’t do it.

  Saturday, 1 May 2010

  I’m discussing a case with my colleague Padma in the coffee room after antenatal clinic, and a midwife leaps into the conversation with, ‘We actually don’t like to use that word any more.’ Wondering what outmoded terminology we’ve accidentally used (Consumption? Scrofula?), she lets us know that we said ‘patient’. We should actually say ‘client’ – calling them patients is not only paternalistic and demeaning, but pregnancy is a normal and natural process rather than a pathological one. I just smile and remember the wise words taught to me by Mr Flitwick, one of my very first consultants, with regards to arguing with midwives – ‘Do not negotiate with terrorists.’

  Padma clearly has no such qualms. ‘I had no idea patient was such a demeaning term,’ she says. ‘I’m so sorry, I’ll never use it again. Client. Client’s much better. Like what prostitutes have.’

  Sunday, 9 May 2010

  Having a poo on labour ward when the emergency buzzer goes off, and within minutes I’ve delivered a baby at crash caesarean section. The second the buzzer sounded I crimped it off, but my wiping was cursory at best, which is why my arse is now unbearably itchy while I’m scrubbed into theatre. It’s acceptable to ask someone who’s not scrubbed – a midwife or ODP – to push your mask or glasses up if they’re falling off, or even to itch your nose. Would it be pushing it too far to ask them for a quick anal scratch?