Your Life In My Hands--a Junior Doctor's Story

by Rachel Clarke

  I too was at work that weekend, assessing acutely unwell patients in my hospital’s Emergency Assessment Unit. As usual, the EAU was bursting with demand and my consultant and fellow junior doctors were wrestling with the challenges of racing against the clock to manage each patient while ensuring we were sufficiently safe and thorough. But even I – social media sceptic as I was – took ten seconds to snap a smartphone selfie and post it on my new, devoid-of-followers Twitter account. Like everyone else, the #ImInWorkJeremy phenomenon had captured my imagination and the Tweet felt like taking a stand, albeit a minuscule one, against government-level misinformation.

  With hindsight, the weekend’s social-media furore encapsulated some of the defining characteristics of the year-long dispute between doctors and the government. First, it revealed that, no matter how carefully the Department of Health laboured to control the message, social media possessed the verve and agility to subvert, on occasion, the intended narrative. The government had taken unusual lengths to manage their ‘weekend effect’ story, going so far as to issue Hunt’s infamous speech to the media on a ‘no approach’ basis, meaning it released the details in advance to journalists only on the condition that they did not approach those it involved. This controversial and infrequently used tactic ensured that doctors’ side of the story did not appear in any of the initial press coverage, giving the Department free rein to try to control its slant.

  The mercurial whims of the Internet, on the other hand, lay beyond the reach of departmental spin doctors. As with the cute cat with its inexplicable 2.3 million fans, who could have predicted that a random doctor’s improvised hashtag would so galvanise the 1.4 million individuals who staff the NHS? Or that it would shift the media message – at least temporarily – away from the allegedly workshy NHS consultants onto the Health Secretary’s sharp practice of implying hospitals at weekends were doctor-free zones. For the Department of Health press office, it must have been infuriating.

  The second salient feature of the weekend’s initiative was the BMA’s role in it: far from leading the #ImInWorkJeremy campaign, the union latched onto it only retrospectively. A single junior doctor had just done more to challenge Jeremy Hunt’s rhetoric than anything the BMA had produced in the last seventy-two hours. The stage was therefore set for a peculiarly modern industrial dispute, one in which the trade union’s activity would regularly be eclipsed by the efforts of its grassroots members – and the smartphone would prove mightier than the sword.

  At the time, none of this was apparent to me. All I knew was that, contrary to Jeremy Hunt’s rhetoric, I had a consultant working alongside me that Saturday and Sunday, with his presence – his deeds – belying the government spin. He had – as always – arrived an hour before his juniors to help shoulder the workload of an acute medical ‘take’ – assessing and admitting all the non-surgical patients to the hospital. ‘Mad Dog’, as we called him, though never to his face, was something of a hospital legend. Close to retirement, he commanded universal respect by combining pragmatism, compassion and encyclopedic knowledge with straight talking, profuse swearing and not giving a damn about bogus authority. Four decades previously, while he was a medical student on an elective placement in a remote Kenyan hospital, local staff had nicknamed him ‘mbwa kali’, the Swahili for ‘mad dog’, on account of his fearsome outbursts whenever he felt a patient had received substandard care, in spite of not yet being a qualified doctor.

  That morning, Mad Dog was desperately needed. Despite it being only 10 a.m. – and a full six months prior to the NHS’s annual winter crisis – a lack of hospital beds was already jamming up our EAU.

  ‘Good God!’ we teased him. ‘What are you doing here? It’s Saturday. Surely you should have parked your Porsche near the eighteenth hole by now.’

  He muttered something unrepeatable involving golf clubs and the Health Secretary and we turned to face July’s eternal winter.

  Unless a hospital has empty inpatient beds into which new arrivals can be admitted, those patients end up marooned in the temporary holding bays of the Accident and Emergency Department and its offshoot, the EAU. Queuing ambulances may now be forced to sit idly on the hospital forecourt, unable to deliver their occupants since all A&E beds are already filled with patients who are themselves unknowingly queuing for the inpatient beds their illnesses warrant. Paramedics, eager to be responding to more 999 calls, must languish in their vehicles, sometimes for hours on end, until someone ekes out a space within the hospital into which the patient – trapped inside the ambulance – can be transferred. Small wonder A&E managers sometimes resort to deploying trolleys in corridors as de facto beds, or attempt to disguise the areas they’ve temporarily stuffed with trolleys with fancysounding names (the ‘Hub’, the ‘Atrium’ – and certainly not the ‘Trolley Park of Last Resort Because the Hospital’s Imploding’). Anything to try to stop the crippling stasis in the flow of patients through the hospital.

  A nasty little phrase – ‘bed blockers’ – beloved of the British press, implies that patients themselves are somehow to blame for this logjam. But of course no one gets in unless someone goes out, and, when the social services – required to discharge frail patients safely – are themselves tightly rationed, the hapless patients don’t stand a chance. Nor, frankly, do the hospital CEOs. No matter how ingeniously hospital management grapples with the challenges of freeing up capacity, when lack of social services can keep medically fit patients trapped in acute hospital beds for weeks or even months at a time, a CEO’s hands are tied.

  Early on in my medical career, when I first saw the stranded ambulances outside my A&E, I found myself wishing I were still a journalist. The system was clearly broken and I believed the public had a right to know this. It was entirely possible in this gridlocked world that, thanks to insufficient funds to fit a stair lift in one elderly patient’s home, somewhere on the other side of the county another patient could be left lying on the floor, post-cardiac-arrest, because the ambulance they urgently needed was pointlessly pinned down on a hospital forecourt. And if the limiting factor was funds, I reasoned, then no amount of paramedics, nurses, doctors or hospital managers could prevent this from happening. The onus was on those controlling the purse strings: the politicians who assured us our NHS was thriving while starving social services of sufficient funds to enable the safe discharge of patients from NHS hospitals. Avoidable deaths, Jeremy Hunt had assured us, mattered to him deeply. Yet some deaths clearly mattered more than others.

  Back in my EAU, patients were piling up in the waiting room. Any one of them could have a potentially life-threatening stroke, blood clot, infection, the works – we just wouldn’t know until we had somewhere to assess them. In every sense, temperatures were rising. Patients and relatives were beginning to look as irate as they were anxious (reassuringly, in one sense: the really sick don’t care enough to get angry). Thwarted and embarrassed, I averted my eyes each time I walked past them, hoping to avoid being targeted by an enraged family member who needed someone upon whom to vent their spleen. My secret assessment room of last resort – essentially a store cupboard with a couch squeezed inside – had already been occupied by a canny fellow junior. There was literally nowhere to see the patients who continued to flood through the doors.

  Respite, unusually, came from my crash bleep. Sometimes, the only effective antidote to the hospital being so swamped with patients that it is impossible to do one’s job properly is the perfect focus of a cardiac arrest. In the tumult of endeavouring to restart a heart at least lies the solace of being able to feel like a functioning doctor.

  With crash calls, you never quite know what you’ll find. By the time you’ve rushed to the bedside, the patient may have already come round from their innocent faint and your presence is entirely superfluous. On other occasions, what confronts you from the pillow is the sickly grey of a face already distorted by lifelessness. Heart stopped, the flow of blood at a standstill, these patients are already dead – it is your job
to bring them back again. There may be uncertainty, even panic among the staff at the bedside, the defibrillator unattached, the chest compressions not yet started. Once – on her first ever crash call – my fellow house officer arrived out of breath at the bedside only to be told by the nurses to stand down since the patient was ‘DNACPR’: their notes apparently contained the distinctive purple form bearing the instruction, ‘Do not attempt cardiopulmonary resuscitation.’ Except – after precious minutes of inactivity while someone hunted down the patient’s missing notes – it transpired that the nurses had mixed up two different patients. The dead patient, the one for whom my colleague had done nothing – and who is haunted still by that knowledge – had been for full resuscitation all along.

  The best arrests are the ones devoid of panic and muddle because someone has taken charge with quiet authority, assigned discreet tasks to each member of the crash team, given a clear running commentary that unifies their efforts, and inspired calm through their own unflappability. This particular arrest was a textbook example. By the time I reached the bedside, a large team of doctors and nurses, led by a senior medical registrar, the grade of doctor just beneath consultant, were already on their second cycle of chest compressions. The initial electric shock from the defibrillator had failed to restart the patient’s heart, but that didn’t mean the next wouldn’t. The team – relaxed, unruffled – appeared to have all the time in the world. It was perfect.

  The patient herself, Mrs Bridges, a married woman in her late seventies with a known history of an irregular heartbeat, had been admitted that morning for treatment of an aggressive pneumonia with intravenous antibiotics. No one seemed to know much about her general health or her home life and, when a second shock failed to kick-start the heart, a heated discussion broke out between the two most senior doctors present: the registrar running the arrest and another registrar from Intensive Care. Were we really, the ICU registrar asked, intending to keep going when an ICU bed was clearly inappropriate for this patient? It was time to call time, to stop this well-meaning but futile activity that served only, at this point, to degrade the patient.

  ‘We’re not achieving anything here,’ he asserted. ‘This is completely pointless.’

  ‘But – who knows the patient?’ I asked. ‘Does anyone here actually know the patient?’

  No one answered. The admitting doctor’s entry in Mrs Bridges’s notes was too sketchy to provide any meaningful insight into her ‘pre-morbid level of function’ – our shorthand for what you used to be capable of before illness struck you down. Amid chest compressions so brutal we all clocked the unmistakable crunch of breaking ribs, the two most senior doctors present continued to argue for and against giving up. Blood slowly seeped across the thin cotton sheets from the artery I’d just stabbed to obtain an urgent blood sample. We looked as if we were committing an assault.

  In an ideal world, the doctors and nurses hovering above what may or may not prove to be your deathbed would weigh the pros and cons of calling off CPR with the utmost poise and gravity. We’d take time, judiciously exploring the risks and benefits of continuing, and with family members, ideally, at the heart of the discussion. But time, of course, is precisely what a crash team lacks. Only a quarter of patients who suffer a cardiac arrest while in hospital survive to discharge and, for those whose hearts stop in the community, the survival rate is less than 10 per cent. Every second’s delay decreases the odds of successfully restarting a heart. And so, in extremis, sometimes dripping with sweat through the effort of pounding the heart, we frantically assess you against the clock, trying to decide if you are worth persevering with.

  This isn’t a matter of egocentric doctors playing God. There are fates worse than death. One, perhaps, is a catastrophic brain injury caused by hypoxia, the brain being starved of oxygen. During cardiac ‘down time’ – when the heart has stopped beating and blood reaches the brain only via the brute force of a set of human fists bearing down on a breastbone – hypoxic brain damage can leave patients in a twilight existence of minimal consciousness in which memory and personality have been lost for good. At any time on my Coronary Care Unit, a kind of intensive care unit reserved for patients with cardiac disease, there are often one or two such patients – saved by well-intended efforts from death, but at what enduring human cost?

  The ICU registrar had marshalled his consultant to the bedside. Both argued in unison that resuscitation must stop. While nurses and doctors deftly swapped in and out of the manual labour on Mrs Bridges’s chest, I could sense the medical registrar leading the arrest starting to defer to the senior presence, the consultant gatekeeper to the beds on ICU. If there was to be no bed for the patient anyway, why continue to strip a human being’s final moments of their last vestiges of dignity? Beyond the flimsy nylon curtains that nominally separated us from the rest of the ward, the conversation was being broadcast to a further twenty-five patients and their assembled families. The matter of whether this particular patient lived or died, it seemed, was about to be determined by which of the doctors at her bedside had the strongest personality, the loudest voice. Rank was now calling the shots.

  I was far too junior to influence anything, but my instincts screamed that we should try a little longer. None of us knew Mrs Bridges. We hadn’t met her, hadn’t appraised her physical robustness for ourselves. Ordinarily, for all we knew, she was fitter than we were. A presumption that her frailty would doom our efforts to failure might be right – but it might not. I felt sick at my impotence. I needed this patient to be given more of a chance. As the daughter of a woman in her seventies who until very recently has liked to relax by climbing mountains and holidaying in the Arctic circle, perhaps I was inherently biased, compromised by sentiment. But I knew a man who wasn’t.

  ‘Run,’ I whispered to the house officer. ‘Get Mad Dog. Get him here now. Tell him it’s an emergency.’

  Meanwhile, I pulled a form of rank of my own. In the rigidly hierarchical world of medicine, the one thing that can trump seniority is territory. Turf, as well as title, matters. The person with whom the buck ultimately stops is the consultant under whom a patient is admitted to hospital, which on this occasion meant Mad Dog.

  ‘I’m afraid we can’t stop CPR until my consultant is here. He’s on his way right now,’ I piped up with as much authority as I could muster. No one liked it, but compressions went on.

  Just as Mad Dog reached the bedside, Mrs Bridges confounded us all. At the next shock from the defibrillator, her heart jolted back into a weak but steady rhythm. We stared incredulously at the ECG trace as a tense conversation between the consultants ensued.

  ‘In the absence of any known evidence to the contrary, I think we probably have to assume a degree of baseline fitness, don’t we?’ asked Mad Dog with all the gentle menace of a medical Vito Corleone. ‘And, given that her pneumonia may respond very quickly to antibiotics, might an ICU bed perhaps be appropriate in this case?’

  It was an offer the ICU boss could not refuse.

  At moments like these – as a junior doctor with neither rank nor experience, feeling out of your depth and overwhelmed by your own ineffectuality – what you crave more than anything is consultant backup. The big guns, fighting your corner on your patient’s behalf. So, in essence, one might argue, events in my EAU that Saturday morning encapsulated precisely why Jeremy Hunt was right: a consultant presence at weekends potentially saved lives. The argument was inconvenienced, of course, by the fact that, rather than teeing up with his mates on the golf course, Mad Dog was here, spending his Saturday in the hospital with me. My entire medical firm was already – undeniably – delivering a seven-day NHS. Something didn’t add up.

  Even in these earliest days of the showdown between the government and junior doctors, I had the sense we were at loggerheads over something far more profound than the terms and conditions of our contract alone. The ferocity of the reaction against Jeremy Hunt felt like an eruption of something deep-rooted and toxic, as though, in chal
lenging doctors’ professionalism, he had inadvertently unleashed years of festering discontent and rage.

  The question that mattered most immediately for me was not whether junior doctors should go on strike, but why we were considering such drastic action in the first place. How had we gone from being enthusiastic ingénues, arriving on the wards brimming with big dreams of healing and making a difference, to angry, defiant, newly vocal campaigners who were damned if they were going to take a perceived degradation in their working conditions from a Health Secretary who had just insulted them? And what, most fundamentally of all, did this explosion of anger tell us about the current health of the NHS?

  CHAPTER 3

  EXALTATION

  As measures of success in medicine go, being offered a gram of heroin by a raving, delirious, intravenous drug user is an unconventional plaudit. But that offer – a semiconscious promise of a Class A drug – made me feel like the queen of the world.

  Mickey was a well-known face in the Emergency Department. Years of shooting up had ravaged most of the veins in his body, leaving only a weeping wound in his groin through which he could permanently inject heroin with ease. Periodically, an infected needle or something unspeakable with which his heroin had been cut would send showers of bacteria careering through his bloodstream, invariably wreaking havoc in whatever part of his anatomy they lodged. At age twenty-nine, one hip had already been ravaged by osteomyelitis – infection deep within the bone – and he’d previously required open-heart surgery to replace a rotting, infected heart valve. Now, the metallic click of his replacement valve could be heard from the end of his hospital bed.