We laughed mirthlessly at the comment, which, though crude and inappropriate, somehow captured the sense of the physical violation inherent in a job that denies you time to eat, drink or even visit a toilet. I held the current unit record for interrupted wee breaks: no fewer than five bleeps from the nurses during one thwarted attempt at urination. Needless to say, no one was the slightest bit interested in our grumbling. In their day as junior doctors, went the consultants’ mantra, it was so much worse – we didn’t know how lucky we were not to be working the 120-hour weeks of old.
Perhaps. But the old days had at least had proper teams of doctors, a traditional surgical ‘firm’, led by a consultant who kept the same set of juniors for six months or more. We were mere shift workers, numbers on a spreadsheet who slotted in and out of days and nights on the roster almost as interchangeably as the patients. No one knew us, let alone formed a meaningful relationship with us. Left, by and large, to our own devices, we would race through our jobs at breakneck speed to try to stop them overwhelming us. We could just about survive fifteen hours of nonstop work, but, when the end of a ‘normal’ working day started nudging midnight, our judgement became blurred and muddy. Sometimes, towards the end of a shift, I felt so drunk with fatigue I could barely pronounce my name, let alone feel confident with patients’ lives in my hands. It felt terribly unstable and fraught with risk, as though at any moment catastrophe might strike. But our warnings to our consultants fell on deaf ears. At no point would anyone above us in the hierarchy admit that the unit was understaffed. Instead, an unspoken yet implied criticism hung in the air: that we were to blame for our excessive hours, failing to conduct ourselves with the expected efficiency.
I wanted to care, I really did. Indeed, sometimes the only thing that gave my day meaning was the time I spent quietly talking to a patient, a moment of focused calm in the maelstrom. But – particularly when forced by another doctor’s absence to do the job of two doctors – that time devoted to my relationship with my patients came at a heavy personal price. Every weekday I’d return to the house many hours after my toddler was asleep in his cot. One Saturday morning, after another ‘forty’-hour week that had turned into seventy, I remember sitting numbly on the floor with him as he crooned with delight in my arms, too tired even to respond. Those extra thirty hours had, as usual, gone unpaid and unnoticed. Week by week, the cumulative effects of exhaustion made maintaining one’s compassion that bit harder. If I were strictly honest with myself, on reading the testimony from the staff at Mid Staffs, I found elements with which I identified.
In one sense, none of this mattered. Plenty of people work long and hard, for a great deal less money than doctors. And plenty of jobs have no autonomy or meaning, whereas – when things go right – being a doctor brings the ultimate reward of feeling as though you have touched someone’s life, helped make a difference when it really counted. It wasn’t that I sought anyone’s sympathy or pity. But I feared that, if my hours and workload continued as they were, I might fail to cling onto the one thing that had driven me into medicine in the first place: my compassion. That or I might just crack up.
CHAPTER 7
HAEMORRHAGE
I couldn’t decide whether I possessed the energy to exterminate my companion. It had been a long night. Normally, stamping on one of the cockroaches that invaded the hospital corridors under the cover of darkness was a particular perk of my night shifts. Infestation control was everyone’s job, after all. But it was approaching 8 a.m., my shift was almost over, and I felt like a dead woman walking, too bombed out to derive any pleasure from dispatching pests to cockroach heaven.
Studies show that the fatigue levels experienced by doctors at the end of busy night shifts can impair their mental acuity more effectively than exceeding the alcohol limit for driving. So, if you become unwell in hospital at the wrong moment, you might find your life rests in the hands of someone who is essentially drunk. Right now, I didn’t just feel inebriated. I felt as if I were face down, fully clothed, drooling into the bedroom carpet, having partied all night and danced until my brain hurt, too tired even to drag myself three feet up onto the mattress. I was still putting one foot in front of the other, walking doggedly to the next ward that had bleeped me, but the feet just didn’t seem connected to the rest of me.
Not that the shift had been devoid of entertainment. In the early hours, as I was scribbling in a patient’s notes in the Emergency Department, Catherine, my favourite nurse, a brilliantly skilled and filthy-tongued young Belfast woman with the strongest Ulster accent I’d ever encountered, was trying to make herself understood. Behind the cheap cotton curtain, her profoundly deaf patient, a man in his nineties, was getting exasperated.
‘What?’ he shouted tetchily. ‘What are you saying? Speak up, young lady. I can’t hear you.’
She tried again, raising her voice. ‘Would you like me to fetch you some medication for your pain, Mr Rogers? For your pain.’
‘What? What’s that you say?’ shrieked a now furious Mr Rogers. ‘Speak up, woman!’
‘Pain, Mr Rogers! Pain!’ shouted Catherine, who always gave as good as she got. ‘Can I bring you something for your pain?’
‘What?’ exploded Mr Rogers. ‘Porn? You mean to tell me you have porn now on the NHS? On the bloody NHS? What kind of nurse are you?’
‘No, Mr Rogers! Not porn. Pain. Pain! Would you like some painkillers?’
I’d left them to it, still going hammer and tongs, relieved that Mr Rogers was unable to hear my unprofessional giggling as I disappeared back onto the wards.
Now, so close to the end of a particularly grim night on the Surgical Emergency Unit – too many jobs, too many sick patients, a workload for two being perilously managed by one – I made the fatal mistake of starting to dream ahead to the end of the shift. Coffee, bacon sandwiches, a long hot shower. The thought of it felt a little hallucinogenic. I could almost sense the bliss of sleep creeping over my limbs. An amateur error. Such indulgence is always punished by some kind of ghastly emergency. On this occasion, it was a fast bleep. Rarely used by the nursing staff, this means they are so worried by a patient that they ask switchboard to summon you urgently by name, a whisker below putting out a full-blown crash call. Unlike the crash call, when a full resuscitation team arrives at the bedside, a fast bleep is received by only one doctor – he or she alone, at least initially, is responsible for handling the emergency.
A few months into my life as a doctor, this was my first ever fast bleep. After the crackle and static, a disembodied voice hissed out of my pager: ‘Dr Clarke to the Surgical Emergency Unit immediately. This is a fast bleep for Dr Clarke. Proceed to the Surgical Emergency Unit.’
The adrenaline surge electrified me. In the space of a second, I went from soporific stupor to wide-eyed hypervigilance. I found myself sprinting to whatever emergency awaited, cockroaches forgotten, heart pounding.
On the unit, the nurses had already swung into action.
‘Bay 5,’ someone called as I burst through the swing doors. ‘It’s a big upper GI bleed.’
My pulse quickened. Major bleeding – haemorrhage – is one of the swiftest and messiest routes to oblivion. A particularly distressing kind of bleeding for both patients and staff is that which arises from the upper gastrointestinal tract: the mouth, the stomach and the tube that connects them, the oesophagus. If an upper GI bleed is too rapid, too profuse, the patient ends up vomiting up their own blood uncontrollably. Old hands in the doctors’ mess had told me you never forget your first time, and this bleed, my first, was a big one.
Jennifer Brownlee was a minute, rake-thin, cantankerous septuagenarian who had been keeping the entire surgical ward on its toes with her abrasive manner and continual demands – for a fresh copy of the Telegraph, a private side room, a better doctor, a more competent nurse. As for many patients with a history of chronic alcohol abuse, years of drinking had scarred her liver into a shrivelled, fibrous husk through which blood struggled to flow. This p
ut her at risk from bleeding elsewhere – in particular the bulging, engorged veins of her oesophagus. Shortly before 8 a.m. that day, one of those overstretched veins had finally burst.
I flung back the bedside curtain to find three or four staff surrounding Mrs Brownlee, who was lying, looking shocked and ashen, drenched in her own fresh blood. The stuff was everywhere. Her face, her nightgown, the curtains, the bedsheets. Even the Telegraph was spattered. No one ever tells you how cloying the smell of large quantities of blood can be. It was like being inside a butcher’s shop.
‘Mrs Brownlee,’ I said with as much authority as I could muster, ‘don’t worry, we will fix this.’
In reality, with rapid bleeds, unless you can pour blood in as quickly as it pours away, in a minute or two your patient will exsanguinate. But that wasn’t what Mrs Brownlee needed to hear at this point. Already, her blood pressure had fallen so precipitously she was beginning to lose consciousness. We had very little time. The nurses had grabbed the kit for placing the biggest cannulas possible in her veins and my job was to site them. As I tied my tourniquet as tightly as I could physically manage, I asked someone to run for O negative blood and bags of fluid. If her blood pressure continued to plummet, Mrs Brownlee would have a cardiac arrest. There was no time for fumbling. My registrar arrived just as I’d managed, to my grim satisfaction, to access the veins, and we were forcibly squeezing bags of blood into our now unconscious patient. An old pro who’d seen everything a thousand times before, he calmly took her to theatre, where his expert hands would attempt to save her life.
As Mrs Brownlee was wheeled away, she left a bedshaped gap on the floor, bordered by the bloody chaos of our footprints. Barely ten minutes after I’d arrived at the bedside, my patient was gone, scooped up by far more skilled hands than mine. My shift, abruptly, had ended. We thanked each other for our roles in the emergency. I noticed I had blood in my hair. Wearily I walked to the changing rooms, peeled myself out of my blood-soaked scrubs and stood for many minutes under the shower, as though water could wash the night away.
Having basked briefly in the satisfaction of feeling as though I’d helped, however minimally, to save a patient’s life, a few days later I was back on day shifts and Mrs Brownlee was back from the dead, thanks to my registrar’s expertise in theatre. But resurrections aren’t always celebrations. The consultant ward round arrived at Mrs Brownlee’s bedside. This particular consultant was a silver-tongued charmer who left half the women on the ward – patients, nurses and doctors alike – starry-eyed and swooning. Mrs Brownlee was one of the seduced.
‘You’re doing marvellously, my dear,’ he crooned. ‘We’re so very pleased with you.’
‘Doctor,’ she beamed back at him, uncharacteristically docile ever since her brush with death, ‘you are all marvellous too. All of you – but especially you.’
Then she paused, frowning darkly. Her eyes had fixated upon mine. ‘Wait. Not that one. That one there isn’t marvellous. She’s a little bitch. She’s a bloody Nazi. Get out of here, you filthy little Nazi! Get out of my sight, you little witch!’
‘Well,’ said my consultant, eyebrow raised at me, ‘I expect that’s the last time you save someone’s life, isn’t it? I’m looking forward to including Mrs Brownlee’s comments in your multisource feedback, Rachel.’
I grinned as we headed off to see the next patient. The real Mrs Brownlee was back – in all her vituperative glory. Tiny, ferocious and irrepressible, I hadn’t realised I had missed her.
Medicine in the UK faces its own major haemorrhage. Doctors are leaving the NHS in droves, an exodus our patients can ill afford. So too are the nurses, midwives, paramedics, physiotherapists and a huge range of other allied health professionals. Currently, England, Wales and Northern Ireland are short of over 23,000 nurses, 6,000 doctors and 3,500 midwives.11 The lifeblood of the health service, the staff without whose goodwill the NHS could not function, is rapidly draining away.
If a journalist points this out to the Department of Health press office, its kneejerk response is to whip out some statistics purporting to show how unprecedentedly well staffed the NHS is under the current government. Jeremy Hunt likes to talk, for example, about the ‘ten thousand additional doctors’ the Conservative Party has brought to the NHS since attaining power in 2010. As always, though, the devil is in the detail. Those ten thousand doctors shrink to only half that when part-time doctors are factored into the mix and, once the UK’s rising population is taken into account, there is no increase in doctors per head of population at all.12 The statistic, like so many others, is a distortion, for political ends, of the yawning mismatch between numbers of staff and patients that anyone who actually works in the NHS experiences day in, day out.
Contrary to the government’s spin, Britain has fewer doctors per capita than almost any other country in Europe, including Bulgaria, Estonia and Latvia. According to OECD figures, we have a paltry 2.8 doctors per 1,000 people, compared with 6.1 in Greece, 4.8 in Austria and 4.0 in Italy.1 Worse, while first-year doctor jobs are fully subscribed, the Department of Health’s own statistics show that, overall, one in ten junior doctor training posts lies vacant, exposing patients to potentially dangerous rota gaps. The exodus of young doctors from the NHS has worsened year on year since the 2010 general election. In 2011, nearly three-quarters of doctors continued in NHS training posts after completing their first two years of practice. In 2012, only 67 per cent did; in 2013, 64 per cent; in 2014, 58 per cent; and in 2015, the most recent data, a mere 52 per cent of doctors continued in NHS training posts after completing their first two years of training, the rest having gone elsewhere, often Australia or New Zealand.13 In some specialities, such as paediatrics, the shortage of trainees is now so critical that one in five training posts is unfilled nationally.
Some media commentators have argued that young doctors who choose to turn their backs on the NHS ought to be punished for their fecklessness by having to pay back the cost to the taxpayer of their years of training. The impression created is one of irresponsible dilettantes being lured by the prospect of a cushy surf bum’s life on the Gold Coast, as opposed to being driven out of the job they love by conditions of work that have become intolerable. Yet across the NHS – spanning frontline staff with different jobs, genders, ages and locations – the chorus of distress is disturbingly uniform. Crucially, for anyone who cares about patient safety, it also chimes with the testimony from staff at Mid Staffs.
Recently, an NHS midwife’s anonymous letter to her local newspaper, the Liverpool Echo, went viral on social media. Like many other NHS staff, I shared it widely online because it seemed to encapsulate some fundamental truths about the working conditions increasingly endured by midwives, nurses and doctors alike, ones that the government would dearly love to airbrush away.
‘I am a midwife and I wish I was dead,’ she began, continuing:
To the outside world I have a lot to be thankful for: house, car, food in the fridge, family who love me, steady job. The truth is that the last on that list is all consuming. It is a black hole destroying my world.
Currently, my caseload is up to 40 women and rising so that’s 80 lives in total that I am personally responsible for right at this very moment. I don’t get much sleep at night. I am unsupported. I have been the difference between life and death more times than I care to remember, seemingly unflappable in the eyes of the parents of the little lives I have rescued from the brink of extinction. They never knew of the tears I cried as I rocked back and forth on the floor of the staff toilet.
I dust myself off as everyone does and it’s on to the next couple, the next birth, and what will that bring? I am scared to attend my next birth as I’m still shaken by the last but we are short staffed at the moment so I just keep my head down and get on with the evergrowing list of things for me to do. An impossibly long list of things to do and I know I will never reach the end, it’s almost futile to try … The hours are endless. Most days I don’t stop for lunch and I freq
uently get to the end of the day without having been to the toilet. Midwives often joke about having cast iron bladders. I’m not the only one. This is so commonplace I fear it’s becoming an accepted norm.
I don’t feel that I am able to do my job safely, let alone provide a good standard of care. I trudge my way through this wretched existence … I have been treading water for some time, I am out of my depth, the tide is drawing me further out and now I am drowning.14
Similarly, in Mid Staffs, the impact of staffing cuts was so distressing to nurses that a group of them wrote an anonymous letter to their directorate manager in order to highlight – futilely, as it turned out – their inability to keep their patients safe given their crippling workloads:
As a ward, despite our exhaustive attempts, we are struggling and on occasions failing to deliver the high standards of care that both ourselves and the Trust aspire to and we request that this be addressed with great urgency … At a recent meeting it was highlighted that our sickness rate was high and the submission of incident forms surpass others. We were asked why. We feel that it is a true reflection of the environment, the unrealistic demands and lack of resources. We all exhausted, mentally and physically. We are fed up with tackling unmanageable workloads, going without breaks, not getting off on time, doing extras with no respite. The environment is neither safe for patients or staff. As registered nurses we are professionally obliged to raise our concerns. We feel compromised, bullied and disempowered. The ward no longer belongs to us. And [on] occasion we almost feel derided.9
These sentiments strike a powerful chord with me today. Statistical spats may be dry and tedious, but the reality of NHS understaffing is as raw and emotionally charged as anything I’ve experienced in either of my two careers. Of course a great many jobs are desperately hectic, but there is something particularly stressful about struggling daily with punitive workloads while knowing that just one mistake, a momentary lapse of judgement, could cost a patient their life.
Your Life In My Hands--a Junior Doctor's Story Page 10