by Ruth Skrine
For the three weeks before the final exam I moved into digs in Sheffield and crammed. Then I returned to Bristol for the papers and clinical tests. The worst experience was the midwifery practical where the external examiner was Will Nixon, professor at UCH and a great friend of my father. He was the nephew of my father’s senior partner in Chippenham and wanted to write a book. With no personal experience of general practice he had asked my father be his co-author. At the end of my case the local professor shook his head and turned away. Will insisted I be given a second case and a second chance. When I read his inscription in the copy of their book, A Guide to Obstetrics in General Practice, published in 1953, I had mixed feelings: To Ruth, who after reading this book should have gained a distinction in the Obstetric Finals examination at Bristol! I was not failing, as I had imagined, but being grilled for a possible distinction.
7
Hospital and Home
A new regulation, first introduced in 1953, the date I got my degree, required all doctors to spend a year in residential hospital jobs before being allowed to practise. I knew I must complete my training – but leaving my new husband for at least five nights a week set up many tensions. Later I was grateful that I had been caught by the new demands, for I had not been a very diligent student and would have been a hopeless doctor without the concentrated experience I gained.
The hospital nearest to our wooden hut was Pontefract General Infirmary where I was appointed as a house physician. Ralph worked in the evenings, having some time off in the afternoons to compensate. On the nights I did get home he was already back at work, not getting in till 9 or 10 o’clock, by which time I was often asleep, having been up several times during the previous nights. I had alternate weekends off but he only got one a month. On those rare occasions that we were free to go to the cinema together he wanted to watch nothing but westerns. I found them violent and hid my eyes in his jacket every time a gun was fired.
Most of his interests were alien to me. He had a passion for classical jazz, while my musical taste had not developed beyond the Gilbert and Sullivan beloved of my father. The martial arts and all things Japanese fascinated my husband, especially the Samurai code of chivalry with its emphasis on loyalty, honour and bravery. He took up archery and shot down the long corridor of our hut. He read about Zen Buddhism and headhunters in the forests of South America. He played chess.
I did not have hobbies. My energy had been focused for six years on passing exams and trying to please people. My mother gave me a subscription to a postal course in household management. Each month a copy arrived with details of cleaning, organising and cooking that should have been a great help in my domestic life. I was furious that she should imagine I had time or energy for such reading and consigned them to the rubbish bin unread.
If we had gone for any sort of pre-marital counselling surely we would have been warned against such an ill-fitting union. Some force had propelled me headlong into the alliance, at the age of twenty-two. Perhaps I was afraid of being ‘left on the shelf’, an unrealistic worry as I was reasonably attractive and did not lack admirers. Unmarried women were common in those days, not because they had chosen such a condition as might be the case in the modern world, but as a legacy of the First World War when the male population had been so reduced. My father’s eldest sister was one of them, stuck at home to look after her elderly mother and handicapped younger brother. I might have been worried that I would become somewhat fey like my aunt Cooty if I remained single. I prefer to believe that some unconscious good sense led me to choose a man who, while not obviously the most outgoing and helpful, was a much better match for my temperament than he appeared to be on the surface.
Now in the second year of our marriage I was spending my days and many of my nights in the company of a motley collection of doctors. I am deeply grateful to Leo Mulrooney, an attractive Irishman who supported me through the first few months. We had no casualty consultant and only one junior in what would become known as Accident and Emergency. The rest of us helped out on a rota basis. The majority of patients were miners with crushed toes or pieces of grit stuck in their eyes. I learned about the rusty ring such foreign bodies could leave in the cornea if not removed adequately; but the most important lesson for me was to look for the injury that was not obvious.
One day a patient was brought in with a damaged shoulder. I suspected a fracture, dislocation or both, and having filled out the form for an X-ray, I turned away. Leo happened to be passing. He twitched back the blanket covering the man’s legs.
‘What about this?’ he asked, removing a temporary dressing that had been applied by the ambulance men.
I looked down at a huge laceration of the thigh. The wound was at least ten inches long and deep enough to expose the bone. Although conscious, the patient was too shocked to complain.
‘It might be a good idea to X-ray this too? Then we can see about getting him patched up.’
I felt my face burning as I realised how cursory my examination had been. After this experience I insisted on examining every part of all casualties, often almost ignoring the obvious injury. As I looked for the damage I might be missing, some patients complained. ‘It’s not my head [leg, back, stomach] it’s here doctor, my HAND,’ or some other part of their anatomy in which they were feeling pain.
After a while, a second Irishman joined us. He appeared to live in order to bet on horses, but never discussed his results. If he passed his cigarettes round with a smile he had probably won. If he sidled up with a murmured ‘got a spare ciggy?’ I knew his luck was out. I was never a heavy smoker but I kept a crumpled packet in the pocket of my white coat for those occasions.
I had graduated from the short white coat worn by students to one that reached below the knee. It had capacious pockets for my stethoscope, patella hammer and British National Formulary (BNF) – and of course my handkerchief. (I have never managed to wean myself onto more hygienic tissues.) The coats were provided by the hospital. A clean one arrived in my room about twice a week, so strongly starched that the sleeves were often stuck together, crackling as I pushed my arms down. If it got spattered with blood, pus or excrement I had to descend to the laundry to try and find a replacement that fitted.
Of course we scrubbed up for the operating theatre but even in the middle of the 1950s we were beginning to be blasé about infections, relying heavily on the magical antibiotics. The insights gained by my ancestor Lord Lister who was the first person to argue against the idea that pus was ‘laudable’, and Pasteur who discovered microbes, were being ignored. Now, the increasing number of organisms resistant to even the most modern antibiotics has led to changes. When I questioned my daughter, who still works in hospital, she replied, ‘No white coats. The rule is “Bare below the elbows. One plain ring, no stones. No wristwatch. Wash or disinfect hands before and after every patient contact.” I think the suggestion is that you wear freshly laundered clothes every day. Many doctors in acute specialities wear scrubs now [the garb for the operating theatre]. BNF lies around on the drugs trolley. Stethoscope usually round neck – not that it gets used as much as it should with reliance on tests etc, but that is probably just me.’
Me too. I am horrified by the stories I hear from friends who been sent for tests without any clinical examination.
In Pontefract the general surgeon covered our work in casualty, but if he was in the operating theatre we had to cope until he could escape. One young man haunts me still. He had a severe head injury and was semi-conscious, suffering from cerebral irritation, making him throw himself about so violently that two porters and two nurses had to hold him down while I tried to cut the surrounding hair and clean the wound. Was that brain I could see? I could not be sure. I stitched it up as well as possible – too well. When the surgeon eventually made his way to the ward he decided to leave my sewing undisturbed. Despite antibiotics it became infected and the boy died three days later. My boss admitted to me that he should have taken the boy to theatre an
d done a proper job but he had been deterred by my tidy, superficial work. We were not wilfully negligent, just two human beings doing our jobs but making mistakes. As so often happens, the grieving parents were some of the most grateful I have ever met, donating a large sum of money to the hospital for the ‘care’ their son had received. Another defensive skin tightened round my feelings.
At the beginning of my hospital work I was the only woman resident. Both the medical and surgical registrars had qualified in India. The former was the best doctor I have ever met. My trust in his judgement was absolute. Although he was half my father’s age he was more knowledgeable. If ever I were in a large-scale disaster, that man is the person I would like by my side to make the decisions. I was particularly grateful for his help when a severely asthmatic young woman was repeatedly admitted to the ward. She was often in extremis and we had no steroids. I had to make do with subcutaneous adrenaline, intravenous aminophylline, given very slowly, oxygen and a tight hold on my panic. Thank you Ramu, for seeing me through those nights.
The surgical registrar was brilliant. I played chess with this man who was not even sure of all the moves but still beat me with a flourish. He was neat and quick when operating but I did not trust him to make good clinical decisions. One patient had been using an electric sewing machine and somehow got her wrist in the path of the needle which had broken and left a piece inside. My knowledge of the anatomy of the wrist was by this time rusty but I remembered our anatomy teacher and her crippled hand. I phoned to ask the registrar to come to casualty.
‘That’s all right,’ he said airily. ‘You are quite capable of getting it out.’
I knew I was not. ‘Sorry,’ I said, ‘I’m not going fishing around in the wrist with all those vital structures so close together.’
He disappeared and the next thing I heard was that the consultant was planning to remove the broken needle in the operating theatre under a bloodless field. (A tourniquet is applied from the fingers up to remove blood from the limb and stop any more entering for the brief period of the operation.) I was shocked that the registrar had asked me to do something he would not attempt himself.
One doctor from West Africa was an enormous liability. His weekends off, when he was away from the hospital and which always lasted four days, were a comparatively peaceful time for me, even though I was doing the work of two people. At least at that time I had the authority to try and rectify his blunders. When he was present he did not examine patients or take their blood pressure but wrote down any number that he thought might be suitable. Drug prescriptions were inaccurate. He made advances to the nurses, who came to me in the belief that I could rescue them, and their patients, from the worst of his excesses. At that time there was no suggestion that I should act as a whistle-blower and report him to the authorities. Today I would be severely censured for not doing so.
Until this time, in common with many of my friends, my contacts had been exclusively white and middle class. My experience of working with doctors of different ethnic groups, brought up and trained in different cultures, taught me that such factors were far less important than individual personalities. In Britain in the twenty-first century the opportunity for that lesson will normally occur in nursery school.
Despite the lack of supervision, long hours and excessive responsibility, there were some ways in which our life was better than that of junior doctors today. We always had a nurse to help us undress the patient and move them in the bed when we carried out an examination, something I understand that even consultants cannot expect nowadays. The turnover of patients was not so fast and each ward had an experienced Sister who knew them well. We always had access to tactful but invaluable advice if we were humble enough to ask for it. This was particularly true on the children’s ward. I had sat in on a few outpatient clinics and walked round the wards occasionally as a student, but I knew nothing of sick children. Paediatric care was part of the house physician’s remit so I ‘took over’ the ward on my first day. Of course, I did no such thing. Sister told me what to do and I did it. She had held the ward together for many years and with her extensive experience she had kept the children safe from the worst mistakes of generations of newly qualified doctors.
We lived close to the wards with a housekeeper who would make us scrambled eggs and other delicacies at any time of the day. On the wards too we were fed, especially at night, with toast or more, when the staff judged we needed it. Because we carried the label Doctor, everyone in the hospital afforded us automatic deference. Like the muscles of childhood that pull bones into characteristic shapes, their expectations helped to change me from a frightened girl to a passable doctor.
At home I also had to adapt, to the strange man I had married. He had no experience of living with a professional woman and although he never made a single overt demand on me, like all men of his generation he expected the house to be cleaned and food to appear as it had always done in his childhood home. Even if he had been prepared to share the household duties in the way most men do in the twenty-first century I would not have welcomed it. I too believed that it was the duty of the woman to manage the home and indeed enjoyed doing so when I was not overtired. I could not have managed without the indefatigable Mrs Nutt. She would arrive from the village on her bicycle to ‘siden up’. That activity consisted of efficient tidying and cleaning but no help with washing or cooking.
When I qualified, my parents had given me a second-hand car of my own so Ralph and I now had our own individual means of escape from the isolation of Pollington. I would buy food on my way home, cook a meal and try to leave something in the fridge for the nights I would be away. Ralph would have been quite happy to live on packet soup and toast but I always felt I was not fulfilling my job as a proper wife. He was fussy about food, the legacy of a sadistic nanny in early childhood. His instinct was to ignore the process of eating but when he developed diabetes he had to take notice, even weighing his food until he could judge the portion by eye. He disliked social meals, using supposed dietary prohibitions as an escape from eating many foods he hated. Most people did not know that diabetics could perfectly well eat liver, stewed fruit, and crab, all anathema to him. I remember cooking a lot of rabbit (myxomatosis did not spread widely in England until 1955). Steaks, fishcakes and rissoles were also acceptable, together with fried eggs and bacon – not the best diet for a diabetic already at higher risk of arterial disease. At that time the long-term risks of a poor diet were less well known. But with my need to provide something he could enjoy, I fear I would probably have ignored the recommendations.
Before my second job started I developed tonsillitis, a recurring problem since childhood. At one time I had begged my mother to let me have my tonsils removed. She was against any intervention unless absolutely necessary and the attacks gradually became less frequent. The one at the beginning of 1954 led to the only occasion when I deliberately played truant from work. I stayed at home for a week with a high temperature but then added another week of unnecessary ‘convalescence’. Jenny came to stay.
Her visit was a heart-warming interlude at that time in my life. I never admitted that I was finding it hard. Indeed I took some pride in coping with what my mother thought was an impossible existence. Then and later, she was so sympathetic about my life, spent moving from what she considered one desolate prison to another, that she made a point of trying to help me make a garden at each place. Outside our hut in Pollington she planted a hedge of Berberis Stenophylla. The plants never grew in the wind and grime, but never managed to die, remaining as stunted little bushes. At times she might have wondered if they were symbolic of my life, so different from the one she had imagined for me.
After Jenny arrived the weather turned very cold and the ground froze. We went skating on a nearby lake. Having lived in Canada she circled with great proficiency while I tottered about on my mother’s skates. The boots were too small but with the cold air on my cheeks I began to recover from the emotional traumas of the prev
ious six months.
The friendship that Jenny and I enjoyed was so deep and solid that it could survive long periods of separation. But during that first visit after I was married, something had changed. Alone together in the open air we were fine. Once Ralph came in we became more stilted. The special closeness of our childhood was only recaptured after both our husbands had died.
Back at the hospital my second job was in the surgical wards. As well as interviewing new patients I had to assist in the operating theatre. I showed little talent with a scalpel and soon changed to helping the anaesthetist who had no junior staff of his own. I was also responsible for many intravenous drips. After I had inserted the needle into a vein in the crook of the elbow the arm was bandaged onto a board to keep it straight. The needles we used were metal and pierced the vein with the greatest ease. Phone calls in the middle of the night were usually to re-site a drip that was running into the tissues. I would put my white coat over my dressing gown, enter the ward bleary-eyed, and be back in bed within ten minutes. Unless there was no suitable vein left to use. Then I had to ‘cut-down’ at the ankle to expose the vein with an incision, a longer and more complicated procedure. The plastic cannula that allows so much more movement had not arrived before my time in hospital came to an end. I have never inserted one.
Sometimes I was summoned from my bed to retrieve the cat. Luck had given me a room with a window opening onto a large balcony, which made it possible for me to adopt her when she arrived in the hospital as a stray. She had found her way onto the ward and snuggled under a blanket until discovered by one of the nurses who threatened to throw her out. The elderly patient had been comforted by her presence and hated to think of her turned out into the night. When I offered to take her to my own room and care for her she was somewhat consoled. Every time the cat found her way back to creep into another bed, the staff sent for me. She gave birth to one family of kittens in a box by my bed, but once they were weaned she left. She was a wanderer by nature.