What I discovered only through first-hand experience was that throughout all the toil of a degree in medicine – the painstaking acquisition of the knowledge and skills that would one day be the bedrock of my practice – I already possessed the quality that, above all others, could make my patients feel cared for: my ordinary, everyday humanity. The transformative power of a kind word or caring gesture was even now within my gift and I could use it, as Precious had, to ensure my patients felt neither abandoned nor alone. Kindness has always meant more than generosity and affection, with ‘kind’ finding its origins in the Old English noun ‘cynd’, meaning family, lineage or kin. For me, the core meaning of kindness resides in this sense of connectedness to – kinship with – others. In the alien, disorienting world of a hospital, I had experienced for myself that an act of reaching out to a patient as a fellow human being, a kindred spirit, no matter how small, could be invaluable. Their absence, on the other hand, made hospital a bleak and lonely place.
It seemed to me that, until now, medical school had largely taught us distance: how to separate from, not connect with, our patients. And nor, arguably, could it be otherwise. How else can a doctor effectively function amid the daily decay, stench and indignities of disease, all the pain and distress that infuses a hospital? Unlike the majority of medical students, I had already seen dead bodies close up during my time documenting the civil war in the Democratic Republic of Congo, and my instincts then were to flinch and recoil. At times I’d had to avert my eyes to stop myself weeping, at others to stop myself retching. I remember one young girl’s leg being cleaned by a nurse as we filmed inside a Médecins Sans Frontièrs makeshift canvas hospital. As so often in Congo, most of the children were machete victims, double, triple or even quadruple amputees after a militia group had overrun their village. But, in this case, it was a bullet wound that gaped like a crater in the child’s thigh and, even to my inexpert eyes, was horribly infected. Perhaps she was ten or eleven. Her screams of pain and pleas in Congolese for the torture to stop went unheeded as, with gentle words but relentless professionalism, the nurse continued the wound care without which her young patient might not survive. The smell of rotting flesh was overpowering and the nurse’s ability to continue working while causing such suffering was beyond anything I could imagine.
Perhaps, in order to deliver a workforce of doctors capable of immersion in the brutality of illness, an essential role of medical school is to build up, not break down, barriers between doctors and the young people they used to be. After all, no one wants their doctor immobilised by sentiment. The acquisition of detachment, the blunting of ‘normal’ human responses to disfigurement and death, might just be what gives doctors the ability to get on and do their job.
More than anywhere else, medical students’ innate taboos are confronted and overcome in the dissection room. Even after I’d witnessed death and dying, nothing prepared me for the act of supreme violation that dissecting a human corpse would feel like.
Over a hundred of us crowded outside the heavy Victorian doors of the anatomy room, waiting to cross the threshold for the first time. A faint scent of formaldehyde hung in the air. That slightly too loud, bravado-driven chatter of people who want you to know they aren’t remotely anxious flooded the corridor. We were first-year medical students, a few weeks into our course. Everyone seemed very young and jittery. Indeed, most of us were still teenagers. Appreciably older, at twenty nine, I was preoccupied with whether I could handle a morning spent precision-flaying a human corpse. My father had regaled me with stories of dissection from his day. Back then, in the sixties, some wisecracking wit would inevitably borrow a human hand from the dissection room and proffer it in greeting to a stranger in the pub, to be met with predictable horror – and the delight and amusement of the assembled medics. Did that kind of thing still happen? I was worried about being too prudish, out of kilter with my fellow students.
In fact, when the professor of anatomy ushered us inside, he did so with the utmost solemnity. Things had changed for the better. We gathered around him, feigning nonchalance, surrounded by a couple of dozen stainless-steel tables, each bearing a body shrouded in white muslin. Out of the corners of their eyes, everyone surreptitiously glanced at the contours of the corpses. The formaldehyde stung my nostrils. I could almost feel it permeating my skin. The walls were lined with shelves upon which jar after jar of anatomical specimen sat, suspended in preservative. Body parts, splayed and pinned, in various stages of dissection. Hands, hearts, torsos, heads. I found myself transfixed by a series of jars in which were marooned human foetuses, graded according to size, from the tiny to the almost full-term. Miniature fists, fiercely poised to leap at life, eyes closed for eternity. I was as prepared as I could be for a wizened old corpse, but I hadn’t anticipated confronting dead babies.
The professor spoke of who the corpses we were about to start dissecting had been. Somebody’s grandmother, somebody’s grandfather. Someone who had chosen, before they died, to subject their future self to our inept blades that we might learn, in clumsy steps, to delay others, undead, from this room and its jars and silver slabs.
‘Each body in this room today is that of a person who chose deliberately to give their body to you. They wanted you to learn. They believed that giving you their body might make you better doctors.’ He paused to survey the room. ‘It is your honour and privilege to dissect these bodies. Imagine someone close to death thinking of how they could help others after dying, choosing to sign the forms that would hand over their body to you.’
As he talked, gently yet authoritatively, like a father to his children, he deftly unfurled a sheet of plastic until there, before a hundred pairs of eyes, lay the body of a man who had chosen to offer up his withered limbs to us and to this peculiar afterlife, measured out in weekly doses of our scalpels’ scrutiny. I couldn’t shake the thought from my head that not even this man’s dearest love had known his body as we would.
During our months of dissection, the professor went on, every scrap of embalmed flesh would be carefully collected and stored. At the end of the year, a church service would be held in which the relatives of the individuals who had so graciously donated their bodies to us would assemble to say goodbye to their loved ones. We were welcome, indeed encouraged, to attend. He knew exactly how to impress upon us the enormity of what we were about to undertake. These were human beings, our kindred who had bequeathed us their bodies, and he expected our respect. Long gone, to my relief, were the levity and japes of old.
We dispersed into small groups around a pre-allotted table and prepared to dissect a human thorax. First, we donned thin plastic gloves and unwrapped the body from its shroud, releasing a concentrated wave of formaldehyde. This would be ‘our’ body for the next six months. Skin grey, eyes closed, mouth open in a perpetual grimace – I found it easier to think of the corpse as an ‘it’ than as a human and hastily volunteered to make the first incision. I think I wanted to break that taboo as quickly as possible. I cut. Embalmed flesh has the consistency of cold wax. There is no elasticity. It slices like refrigerated parmesan. What in any other circumstances would have been a crime, the defilement of a corpse, was now our twice weekly ritual.
In those early days, so long as I didn’t look at the face and refused to think of the corpse as he once might have lived, I found I could suspend my instinct to recoil. Swiftly, though, no mental effort was required. Familiarity bred detachment and, after only a couple of sessions, I came to love dissection. The physical craft was only the start of it. Learning anatomy, it turned out, was part linguistics, part cartography. Slowly but surely, I began to label in Latin every bone, nerve and muscle of the human body, lovingly mapping what had once, for me, been uncharted territory. Anconeus. Brachialis. Lunate. Triquetrum. The new language in which I was gaining proficiency seemed as exotic as it was beautiful.
Sometimes, lying on the sofa late at night revising my anatomy, I’d make a small movement – turning my hand inwards or fl
exing my thumb – and rehearse the Latin that described the intricate engineering underlying the action. The mere act of raising my little finger, for example, involved extensor digit minimi, the lateral epicondyle of humerus, the fifth metacarpophalangeal joint, the posterior interosseous nerve. Being able to visualise and whisper every part felt like earning exclusive membership of a secret society. The excluded, in this case, were the general public. More than once, my boyfriend caught me staring intently at the sinews of his arm or the veins of his neck, knowing full well the look wasn’t lust but merely my latest attempt at reading his flesh. At the time, this didn’t strike me as odd, although, with hindsight, I must concede amazement that he married me.
Like the formaldehyde that seeped into our skin and clothes, lingering long after we had left the department for the day, my relationship with the human body was enduringly altered by the experience of dissecting it. Before, the bodies of others had been, among other things, objects of desire, beauty and limitless comfort, when I considered the potency of a simple human embrace. But now they were also texts to interpret, with inner meanings to lay bare. Behind a spontaneous smile of greeting I saw risorius and zygomaticus major and minor elevating the corners of the lips into their upturned welcome. The classical lopsided facial ‘droop’ of a stroke, on the other hand, told me that the seventh cranial nerve controlling these muscles had been impaired by a mishap in the brain.
The price of six months in the dissection room was undoubtedly a loss of innocence. Bodies hadn’t shed their beauty or desirability, but in death they no longer held the power to disturb. More than anything, what dissection taught me was the vital skill of distancing myself from my patients. Rather than worry about my newfound toughness, I’d been hardened in a way I approved of. I couldn’t imagine a place for squeamishness in the doctors’ mess.
CHAPTER 6
CALLOUSNESS
The first few years of a degree in medicine used to be devoted to giving students an exhaustive grounding in anatomy, biochemistry and physiology before letting them loose on the wards. The preferred model these days is for the students to encounter patients from day one, alongside the acquisition of theoretical knowledge, with the intended benefits of helping students feel comfortable around patients and of embedding all that theory in a meaningful context. A few universities still prefer the old style and, being something of a single-minded purist, I chose one of the few remaining traditional medical schools: total immersion in theory for two years followed by another three of living and breathing the hospital. I wanted the academic knowledge under my belt before surrounding myself with patients. Consequently, just before commencing my three years of clinical medicine, I knew next to nothing about its practice.
At this time, my grandfather, himself a retired doctor, was rushed one day to hospital, having collapsed from an irregular heartbeat. At ninety-two, he had been a doctor before the NHS even existed, spending the Second World War on a Royal Naval destroyer in the North Atlantic, protecting Britain’s lifeline of food and supplies from America. His military officer’s bearing never left him until his final days in hospital. After the war, he had become a general practitioner in the days when GPs were often the rocks of their local communities. My younger self thrilled at the story of him carrying one of his elderly patients from the flames of her burning home, after the fire brigade had deemed it too dangerous to enter. As a child, I hung on his every word.
Of the scores of stories I never tired of hearing, my favourite took place in his local greengrocer’s, just after the end of the war. The grocer, whose children my grandfather had delivered in a downstairs bedroom, ushered him into a room at the back of the store.
‘I’ve got something for you, Doctor,’ he said, conspiratorially. ‘I want you to take this home and give it to your family. They’re the first ones we’ve seen since 1939. Give them to your children.’
He produced a large cardboard box, wrapped in brown paper and tied with string.
‘Don’t open it now. Take it home.’
As my grandfather carefully unwrapped the paper in the seat of his car, the concentrated aroma of a couple of dozen oranges flooded the vehicle. Almost garishly bright, the fruit looked impossibly exotic after years of wartime rationing. He sat for a while, contemplating his gift, then set off decisively, not on the route back home but up the hill to the local sanatorium for children with tuberculosis. In those days, with antibiotics still in their infancy, the only widely used treatments for tuberculosis were rest and fresh air, each as ineffectual as the other. Most of the young patients in the sanatorium were pale and skeletal, inexorably wasting away. My grandfather was well known to the staff.
‘Dr Rendall!’ welcomed the sister. ‘Come in, come in.’
‘Can’t stay, Sister,’ he said, handing over the package. ‘Just called by to drop off something for the children. Here. I hope they enjoy them.’
Now my grandfather was himself in an institution, one of the acute medical wards of his local hospital. We had left him there earlier that day, frail but comfortable, on a cocktail of medications for his heart. That night, like most men in their nineties, he awoke with the need to pass urine. It was three in the morning. Though his hospital bed was only yards from the toilet, he was well aware that, at age ninety-two, deconditioned by illness, attempting to reach it unaided was fraught with jeopardy. He risked a fall he was too debilitated to survive. My grandfather was not a man for whom asking for help came naturally. Nonetheless, he pressed the button at his bedside to summon a nurse’s assistance. Once, twice, multiple times. But, in the eternal twilight of a hospital at night – the incessant bleeping of blocked intravenous drips, the whining of the automated blood-pressure cuffs – flesh-and- blood nurses are thin on the ground. An old man needing to urinate commanded no one’s attention. Time crawled by.
By 5 a.m., the choice he faced was stark. He could give in to the burning pressure in his overstretched bladder, soiling himself in his hospital bed, or he could attempt to stagger unaided to the bathroom. Possible calamity versus certain indignity. Falling onto hospital linoleum or spending what remained of the night lying soaked in cold urine. I imagine my granddad, this larger-than-life former NHS doctor, gingerly shuffling his six-foot frame to the edge of the mattress in the semidarkness. Gripping the bed for support, steadying himself for a moment, then clumsily rising to standing. A foot extended, a first attempted step. And then the fall, the smack of cranium on floor, the drip stand collapsing on top of him. How long he lay semiconscious is unclear. But, when his son, my father, arrived the next day at his bedside, he found his own father battered and bruised, in considerable pain, with a newly paralysed left arm hanging by his side.
The medical registrar on the morning ward round faced a doctor’s worst nightmare: a relative who was himself a doctor, brimming with terse questions about his loved one’s apparent mistreatment.
‘Who examined my father’s neurology after the fall and what were the findings?’
No one, it seemed, had bothered.
‘Well, my examination just now indicates left-upper-limb paralysis and a large cervical haematoma. I suspect my father has had a broken neck since yesterday morning.’
There was a pause, a painfully long one.
‘Did no one on your team consider examining him or imaging his neck? Not even your consultant?’
The hastily organised CT scan confirmed that my grandfather had indeed fractured a vertebra in his neck. He lasted two more days, awkwardly trussed up in a foam collar, before dying at night in a hospital side room.
At the time of my grandfather’s death, my father’s bedside advocacy on behalf of his own father barely made clinical sense to me, still steeped, as I was, in only the theory of medicine. All I knew was that the manner in which he had died was terribly, inexcusably wrong. And, even now, I find that imagining anyone – let alone someone I love – reduced to such indignity causes me to recoil inside.
No one, I was certain, had set out to tre
at my grandfather unkindly. Nonetheless, through their failure to answer his buzzes for help – their seeming indifference – the night staff on his ward had indirectly caused him to suffer torment, humiliation and an ultimately fatal fall. It never occurred to me, as yet unexposed to how precariously staffed a hospital at night can be, that the nurses may have had no choice, too few of them stretched too thinly across too many patients. I struggled, perhaps naïvely, to see how this could have happened in any hospital, let alone in what was ostensibly a centre of NHS excellence. Something must be rotten, I reasoned, if staff who had chosen to devote their professional lives to caring for others were somehow, through inaction, so degrading their patients. Haunted by the gulf between the man I had loved and the shadow to which the hospital had reduced him, I felt that the NHS on this occasion had lost its humanity entirely.
Unbeknown to me, at exactly this time – in 2005 – patients in another UK hospital were being subjected to casual cruelty en masse. For years, the hospital in question, the Stafford, part of the Mid Staffordshire NHS Foundation Trust, treated patients with such shocking brutality that ‘Mid Staffs’ has since become a shorthand for the most barbaric failings of NHS care imaginable. While concerns about mistreatment and excessive mortality rates started to emerge in 2007, it took another two years before these were properly investigated. Hundreds of patients were estimated to have died unnecessarily in Stafford Hospital, now renamed the County Hospital and administered by University Hospitals of North Midlands NHS Trust. After increasing pressure from bereaved families, the government commissioned Sir Robert Francis QC to conduct two inquiries, one of which was a full public inquiry, into what became one of the biggest scandals in NHS history. His reports paint an extraordinarily detailed picture of routine neglect, humiliation and brutality at the hands of NHS staff:
Your Life In My Hands--a Junior Doctor's Story Page 8