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

by Rachel Clarke

  What if, instead of individuals’ emotional failings, it is warped conditions of work within the NHS that are driving doctors and nurses to the edge? The debilitating pressures of constantly operating in an environment that denies you the resources to do your job safely? A little like facing Helmand with peashooters, to borrow the military analogy of which NHS leaders can be so fond. Under those circumstances, an online course in tick-box ‘resilience’, while welcome, may be doomed to failure, ignoring as it does the fundamental factors eroding doctors’ and nurses’ capacity to bounce back.

  ‘Resus’ is where patients are sent when doctors worry they might die. We were waiting around this particular empty resuscitation bed like predators poised to pounce. Emergency attempts to save a life are often brutal, and resuscitation, when the team first descend, can horrify any next of kin who witnesses it. None of us spoke. The paramedics had called in the trauma to A&E with sufficient warning for a full team to be assembled, our roles pre-assigned and displayed on the cardboard signs we now wore pinned to our scrubs. Our team leader, a seasoned trauma consultant, had the kind of battle-weary composure that inspires total calm. It was, as so often, a road-traffic collision. All we had been told was that the victim was young and unconscious. She had been hit by a lorry while walking through town. A mobile phone was rumoured to have been involved. No one knew anything for certain. But we were ready to launch into coordinated action the moment she swept through the swing doors.

  I was ‘Doctor 2’, the most junior doctor in the team. I felt awkward in the bulky lead apron I wore to shield me from radiation, should bedside scans be required. This was my first time in a trauma team and I was desperate to do a good job, staying calm and focused no matter how bloody the unfolding events proved to be.

  As the paramedics rushed the patient into resus, we descended en masse, as one. Seamlessly, one nurse attacked clothing with scissors to expose bare flesh, while another applied electrodes and oxygen. The anaesthetist assessed the girl’s level of consciousness, deciding whether or not she required urgent assistance with breathing. Several policemen hovered in the background. I shoved a cannula in the largest vein I could find, then stabbed the main artery in the wrist to provide a sample of arterial blood. In under a minute, a fifteen-year-old girl – her name was Chloe – lay naked but for her knickers, the plastic collar protecting her C-spine and a tangle of plastic tubes and wires. There was no blood, no bruising, no mangled limbs, nothing to suggest her recent impact with a twelve-tonne truck. She was, in a word, perfect. Her body was flawless – it had the kind of litheness and beauty possessed only by the very young – save for one devastating detail. From her nostrils trickled a trace of clear fluid. You might barely have noticed, had you not set out to find it. Cerebrospinal fluid – the liquid that surrounds and cushions the brain and spinal cord – was leaking out of her skull through her nose. Beneath its immaculate exterior, her head had suffered a blow of such force it had fractured the skull into pieces, allowing the telltale seepage of fluid. Who knew the state of the brain beneath? She began to groan and flail at the hands that accosted her. Probably, she was cerebrally irritated – blood was inflaming the meninges, the protective layers in which the brain is wrapped.

  An urgent CT scan of her head confirmed everyone’s worst fears. Chloe’s skull was shattered in five separate places, her brain swollen and clouded with blood. Though her body lay unblemished, we had no way of knowing if the person she had been was preserved. I was not there when her parents burst into resus, but I heard their screams, reverberating all the way to the other side of the department. The father, one of the nurses told me afterwards, had collapsed to his knees at his daughter’s bedside.

  In an NHS Emergency Department, the queues of patients never end and there is no time to dwell upon any of them. You move on, do your job, refuse to indulge your own feelings, because your next patient deserves better than an emotion-addled doctor. But that night, and for several more afterwards, Chloe’s image – this pale, perfect girl on the cusp of adulthood – floated into my dreams. We would be crowded round her bed again, fighting to save her, while knowing she was slipping away. I held my children extra tightly that week and chose not to follow her progress on neuro-intensive care, preferring instead to believe in those uplifting patients who once in a while defy their doctors’ pessimism.

  It was by no means the bloodiest or ugliest of my early medical experiences, yet for a while Chloe continued to haunt me. I imagined the banality of her chitchat with a schoolfriend, giggles and gossip about last Saturday night; then, from nowhere, never glimpsed, twelve tonnes of truck bearing down, a mobile phone bouncing off the pavement, a body lying still in the road. The mother in me recoiled. No quantity of parental love, hope, fear or grief ever protects against the casual indifference of whom A&E decides to summon to its bays.

  It is this, in one sense, that the GMC was latching onto – and rightly so. As Terence Stephenson put it,

  During one day last week seeing emergencies, I cared for a child of seven with an incurable life-limiting condition who will not survive until 17, and a 17-year old who took a life-threatening paracetamol overdose because she cannot face the next day. Despite 32 years as a doctor, seeing patients suffering is still very stressful for me so how much more difficult must it be for a recently qualified doctor? … Without developing a psychological ‘carapace’ or some ‘emotional armour’ which allows one at the end of the day to hand over care of patients to the night team, to go home and not agonise over these worrying patients, doctors can burn out.76

  Stephenson is partially right. When you are a doctor, a bad day at the office might mean, ‘She has catastrophic brain damage’; ‘He won’t walk again’; ‘We lost the baby’; ‘We did everything we could, but we couldn’t save him.’ A bad day is disability, death or grief of an order that cuts through the routine hospital backdrop of recurring loss and pain. A bad day makes you want to tell the world to please go to hell because only cursing, or maybe alcohol, makes you feel better. If you cannot face raw human suffering, medicine is not for you. But, equally, when your job is not killing but healing, the notion that good doctors must be clad in ‘emotional armour’ risks the unintended harms of numbed and battle-scarred clinicians, all too evident in the drivers of the scandal of Mid Staffs.

  In my experience as a junior doctor, what makes me resilient – able to function with the mental elasticity to absorb the stresses of the job I chose, weaving them positively into my working life – is, above all, other people. My colleagues, my mentors, my team. I am nothing without the doctors and nurses with whom I work every day. Break down the human relationships that sustain and nurture a medical workforce, and you risk creating doctors who first lose their compassion, and then become too brittle to remain in work. Patients are best served by neither.

  ‘What the hell is going on with our patients?’ asked Sally, my fellow junior doctor, as we worked our way through a bottle of wine. ‘You do realise more of them have died this month than lived?’

  It was our first month on haematology, the speciality that, more than any other, is accused by other doctors of inappropriately poisoning its patients, refusing to pull out and permit dignified deaths. Sometimes, this boils down to misunderstanding. Blood cancers such as leukaemia are not like other malignancies, where cure rests on cutting out a tumour. In leukaemia, where the cancer is spread throughout the blood from the outset, it is often only the ‘poison’ – aggressive, even life-threatening chemotherapy – that gives the patient a shot at a long-term survival. But the stakes are high. Chemotherapy attacks not only the leukaemia cells but also the healthy bone marrow where all the other, noncancerous blood cells are made. If a patient’s bone marrow begins to fail, this puts them at risk of potentially fatal bleeding or infection.

  I had never seen such a collection of desperately unwell patients as in my first few weeks on a haematology ward. Most of my patients were there for bone-marrow transplants, where someone is subjected to c
hemotherapy so devastating their entire bone marrow is wiped out, including – or so we hope – every trace of leukaemia. Marrow from a donor, perhaps a sibling or another closely matched relative, is then transplanted into the patient, replacing what we have destroyed. If the marrow successfully ‘takes’, and if the patient does not die from bleeding, infection or the powerful immunosuppressants they will now have to take for the rest of their life, then maybe, just maybe, they will be cured. Poison, I had to admit, was rife here, and with the poison came the deaths.

  First, a mother to three young children succumbed, in increasing pain and fear, to the ravages of what can be one of the most brutal blood cancers, multiple myeloma. Next, in swift succession, several of our patients with bone-marrow transplants died. But the most searing experience, for me, in this relentless month of deaths, was a night spent looking after an unusually young patient admitted earlier that day onto our ward. At eighteen, Azra had never really known life without leukaemia. Diagnosed while still a small girl, she had spent years in and out of hospitals receiving chemotherapy, radiotherapy and transplants. Now, she had arrived with her father, gasping for air and clutching a small, scruffy bunny, a much-loved comforter since birth. Her leukaemia may have been at bay, but her lungs were overwhelmed with infection. In someone with a normal immune system, the bug in question, cytomegalovirus, is rarely even noticed, but, in the lungs of an immunosuppressed patient, it can wreak absolute havoc.

  As the night wore on, Azra’s temperature soared and her breathing became more ragged. Her father’s face wore the drawn expression of someone who confronts the abyss. In spite of giving powerful antiviral medications through a drip and the most concentrated oxygen we could administer, Azra’s oxygen saturations continued to fall. I could see the fear in her eyes every time I came towards her, doctors at her bedside invariably meaning limbs stabbed with needles or worse. She clutched her threadbare bunny to her side, as if a talisman against the pain I might inflict. She did not know it, but my pleas to allow me to take a sample of her arterial blood – a procedure that is invariably painful, sometimes exquisitely so – had her best interests, her life, at heart. Without an accurate recording of her oxygen levels, Intensive Care would never agree to giving Azra a bed. Even when finally armed with the dire oxygen readings, I faced an ICU registrar who bristled with hostility.

  ‘The trouble with you haematologists is, you just can’t stop poisoning your patients, can you?’ he glowered.

  My own registrar was managing another equally unwell patient, the ICU registrar didn’t want to know, and Azra, I feared, was going to die on the ward without the invasive therapy only ICU could provide. I felt alone before a father’s beseeching stares and his daughter’s naked fear. Finally, mercifully, the daytime haematology registrar arrived, took one look at me and asked what was wrong.

  ‘It’s Azra,’ I told him. ‘I think she’s going to die if we can’t get her to ICU. Please, please try to get her there.’

  We exchanged a look. In that instant, I knew he knew what the night had been, the desperate scrabbling to hold onto a life that you fear might be slipping through your hands. Of course he knew. Like every seasoned registrar, he had been there a hundred times before.

  ‘OK. Just go home, Rach. Get some rest. I’ll sort this out.’

  My gratitude, exaggerated by sleep deprivation, left me close to tears. I knew Azra was now in safe hands. Returning to the ward that evening for the next of my night shifts, I found she had been sent to ICU shortly after I had left, where she now lay attached to a ventilator machine that mechanically inflated her ravaged lungs. She never managed to breathe again by herself and died, still ventilated, several days later. You could argue that ICU had been perfectly correct in their original assessment not to admit her, whereas my judgement had been clouded by sentiment. When ICU beds are like gold dust, only those patients with a genuine chance of survival earn the right of occupation.

  Back in the pub, as I discussed with Sally the trials and tribulations of haematology, even Azra’s death lost its sting. No explanations were needed. We had already shared so many deaths, bad deaths, the ones where you cannot shake the feeling that your years of toil and study have failed you, failed, above all, your patient. Our camaraderie was forged in each other’s worst moments – the angry, exhausted, bitter, hollow times – and the solace this afforded, more than anything else, was what kept us cheerfully going on. Nothing helps resilience quite like knowing you are in it with your comrades-in-arms. Before long, we were laughing. Black humour, certainly. Jokes you could never repeat to a non-medic. The slightly twisted take on dying that brings you back to the wards, renewed, heartened and ready for more.

  Sometimes, on returning home after a long shift on call, the first thing I need to do is wash it away under a scalding shower. Then, an obligatory large glass of wine to take away the hard edges. Talking to my family is not an option. A husband neither wants nor needs to know that today you were called to a crash call where the patient was vomiting up blood so profusely his circulation crashed and he suffered a cardiac arrest; that security guards scrambled to clear the public from the route between the ward and the operating theatre; that, as the crash team ran with the bed down the corridor, you knelt atop its blood-soaked sheets, pumping the patient’s chest with such force you feared you might lose your balance and topple to the floor below; that in theatre, despite the surgeons cracking the chest, wrenching the ribcage apart and manually compressing the heart, it never regained a rhythm; that later, long after the time of death had been called, when you stripped off your sodden clothes, you found even your underwear was bloody. Why would he want to hear this? Why, frankly, would anyone? They say nothing is thicker than blood. But even genealogical ties do not bind as tightly as those blood ties to my other family, the one with whom I share the daily sorrows and trauma of life inside a hospital.

  These days, when not calling for compulsory resilience, NHS leaders are invariably agonising over rock-bottom morale among NHS staff. And rightly so. Low morale is linked not only to sickness but also to lower standards of patient care. NHS England has estimated that sickness absence costs the NHS a staggering £2.4 billion a year. If that sickness absence were reduced by only one day per person per year, the NHS would manage to save £150 million, enough to pay for six thousand additional full-time staff.41 Put simply, there is an enormous financial incentive to cheering us up. In 2015, the chief executive of NHS England, Simon Stevens, summarised the economic argument for improving staff morale and wellbeing:

  NHS staff have some of the most critical but demanding jobs in the country. When it comes to supporting the health of our own workforce, frankly the NHS needs to put its own house in order. At a time when arguably the biggest operational challenge facing hospitals is converting overspends on temporary agency staff into attractive flexible permanent posts, creating healthy and supportive workplaces is no longer a nice [thing] to have, it’s a must-do.42

  But Stevens’s implicit accusation that the NHS is to blame for its own morale issues is somewhat rich, given the political and financial constraints under which every NHS institution is forced to operate, and over which the government and Treasury exercise control. While I would dearly love my hospital to treat me with a little more kindness, a little less indifference – and undoubtedly there is much work to do here – a Zumba class or two is never going to come close to addressing the corrosive impact on our daily working lives of navigating the gruelling workloads caused by insufficient numbers of frontline staff. And, in an era when hospitals are being expected to slash their expenditure under the guise of ‘efficiency savings’, the pressure is on them to shrink, not expand, the size of their wage bill.

  Recently, a doctor writing anonymously in the Guardian encapsulated perfectly the conditions that can defeat the most resilient of doctors:

  It’s the start of my night shift in the district general hospital as the medical registrar. I’m on my own and I know it … All six beds in resus
citation are full. Two patients require machines to breathe: one is alert, the other is already anaesthetised. Anyone who can’t talk, as a general rule, needs to be seen immediately. However, these sick people cannot be moved from their temporary beds in A&E – there are no beds free in the hospital … It’s going to be a long night. I see the exasperated paramedics in a queue; they can’t drop patients off. My juniors, just two of them for 150 patients, get to work, but it is hard. There is nowhere private to see people. They are reduced to clerking patients on trolleys and chairs – it’s not dignified.43

  The stamina required to get through a shift like this – and every doctor has worked them – fills you with anticipatory dread. The chaos, the pitifully small number of on-call doctors to tackle the onslaught of patients, the potential risks of the lack of bed space, the fact that no one in the hospital wants to hear about any of it. Perhaps most souldestroying of all is that, too often, at the widest level – in the national conversation between politicians, journalists and commentators about the state of the NHS – it can sometimes feel as though no one is willing to confront head-on what is actually happening on the ground. This is precisely the sort of denial, a kind of wilful collective blindness, whose dangers Sir Robert Francis warned of, except that, in this case, it operates at a governmental rather than Trust board level. Morale is built on belief. But how can NHS staff maintain theirs in the institution they love and serve when its political masters appear to be turning a blind eye to its slow, inexorable demise? As the medical registrar in the Guardian put it,

  In a moment of clarity, at 1am after I have barely stopped to breathe and an elderly lady has died in my arms, I ask myself: ‘Is this not supposed to be a developed country? Do we not care for our people? Do we really accept that this is the way it needs to be? Doesn’t anyone out there care that there are no beds?’79