CHAPTER 12
WONDER
‘Quick! I need a medical student! Someone get me a medical student.’
The head sticking out of the consulting room door had the wild-eyed zeal of a shaman in the grip of a vision. His excitement was impossible to resist.
‘Me!’ I yelled, happening to be walking by on my way to the hospital canteen. ‘I’m a medical student!’
The consultant closed the door behind him, furtively checked the corridor for nearby patients, then bent down conspiratorially towards me. ‘What I’m about to show you is absolutely incredible. You’re never going to see anything like this again. This man’s got a triple A so enormous I can’t believe he’s not dead. For Christ’s sake, be gentle when you feel it.’
I could hardly believe my luck. An abdominal aortic aneurysm, or triple A, as we call them, is caused by a weakening in the wall of the aorta, the most major blood vessel in the human body, which mainlines blood straight from the heart to our extremities. Slowly but surely, the furiously pumping blood causes the damaged portion of this gigantic artery to stretch ever more thinly until, unless a doctor intervenes, the inevitable happens and its strained walls burst. Then, without emergency surgery, the patient will be dead within the hour, as five litres of blood are dumped unceremoniously into the abdominal cavity. But, these days, triple As are no longer a death sentence. Having often picked them up as an incidental finding on abdominal scans performed for unrelated reasons – or during routine screening - the surgeons then keep a careful eye on them, repeating the scans at regular intervals to monitor their size. We know that small aneurysms are unlikely to rupture but, once they approach the size of a satsuma, the odds shift dramatically against the patient. Now, they are living with a primed grenade in their belly. One in four patients with a six-centimetre triple A will be dead within a year.
The really big aneurysms – the ones that could blow at any moment – can sometimes be seen from the end of the patient’s bed, pulsating visibly below the patient’s ribs like a subcutaneous alien life form. Once they begin to bleed, the chances of surviving are desperately slim. This one, the surgeon told me, felt as if it was at least nine or ten centimetres in diameter. By rights, the patient should have bled out long ago. He had only come to clinic about his varicose veins but the surgeon was old-school and believed in examining everything. For me, never having seen, let alone laid hands on, a triple A, it was almost too good to be true. Gingerly – almost reverentially – I placed my palms above the umbilicus, fingertips just touching, as though offering up an impromptu prayer for the patient’s survival. As blood surged into the aneurysm with every heartbeat, my hands were thrust apart, fingertips surfing the lifeblood of this middle-aged man who, thanks to one doctor’s thoroughness and skill, should now escape what would have been almost certain death. My textbooks and lectures had just come to life in unforgettable Technicolor. I glanced up at the surgeon, eyes gleaming with delight and gratitude that he had taken the time to share the case with me. He grinned. ‘I’m finishing clinic shortly – wait for me outside.’
The surgeon, having finished explaining the pros and cons of surgery to the patient, shared with me an anecdote from the early days of his career. While still a very junior doctor, he was working in an Emergency Department when a fairly elderly man arrived with an unusual story of pain in his abdomen. Early that morning, the septuagenarian and his wife had been climbing Helvellyn, one of the Lake District’s most precipitous peaks. During the ascent, a niggling pain in the belly had gradually become impossible to ignore. He had insisted upon reaching the summit before admitting to his wife that the gnawing pain now drilled all the way back into his spine and was so intense, it was making him feel light-headed.
‘Well, there’s a hospital at Penrith,’ she told him, ‘so let’s drive there, darling.’
‘I’m not bloody well going to Penrith. If I absolutely must go to an A&E, then it’s bloody well going to be the best, so we’ll have to get back to Cambridge.’
Some thousand metres of descent on foot and two hundred miles of motorway later, Mr and Mrs Sinclair finally reached their local hospital in Cambridge. He had driven the whole way himself. Sweaty, grey and with his pulse racing, Mr Sinclair was clearly not well on arrival in hospital. But the surgeon, to his surprise on feeling the abdomen, discovered an enormous, pulsating aortic aneurysm, just like the one I had felt earlier except for the small matter that this one had been oozing blood for the past twelve hours, even as its host had summited Helvellyn. No one survives a leaking triple A for twelve hours. No one except, perhaps, a mountainclimbing seventy-something who unwittingly splints his bleeding aneurysm with his seatbelt, now successfully acting as an abdominal tourniquet.
‘It was a miracle,’ the surgeon told me. ‘How he had walked into A&E alive I will never know. We took him straight to theatre and he survived. Went home a week or so later, perfectly well. Insane.’
The best antidote I know to despondency and gloom is the prevailing hope of others. Wonder, like hope, is contagious and, years before I ever set foot inside a medical school, I was permanently infected by my father’s. To non-medics, doctors can be mind-numbingly boring. We cannot resist obsessively discussing medicine – to us, our patients and their illnesses are endlessly enthralling. It is undeniably a little odd, for example, to have a spring in your step for an entire afternoon because you have just felt your first pulsating aneurysm. It is also frankly peculiar for a patient’s life-threatening pathology to become the highlight of their doctor’s week. But amazement, awe and admiration for medicine infuse many students’ first encounters with their subject and, occasionally, resurface among even the most cynical and grizzled of consultants.
At the tail end of the junior doctor dispute, one of my doctor friends sent me a message that struck a chord. She was at a low ebb after what felt like a squandered year of futile campaigning, and her message was poignant: ‘I’m worried I’ve lost the keeno lifesaver light.’
I had never heard her way of putting it before, but I knew exactly what she meant – a young doctor’s insatiable urge to learn everything, to devour all the facts and the experiences in order to save patients’ lives. At medical school, it was the ‘keeno lifesaver light’ that kept me sitting in the front row of every lecture, the infuriating one who always had her hand up, desperate to ask another question. It kept me poring over my textbooks into the early hours until I had properly mastered my biochemistry. It kept me loitering on the wards to chat with the patients because a dusty account of a disease from a library book came to life for me only when fused with someone’s lived experience of their illness. Fellow keenos were everywhere: the doctors, far too busy to take time out to teach, who did so anyway, sacrificing their own time to inspire and enthuse new recruits like me, teaching us how to diagnose which valve of the heart was failing from the arcane whisperings our stethoscopes picked up, or which neurological disease a patient had inherited from the shape of their calves alone.
I discovered that not even a year of opposing the government could entirely extinguish the keeno light when, shortly after I had withdrawn my application for speciality training, one of my patients revived my curiosity of old. Dr Talbot, a retired academic, had recently returned from a trip with her husband to the Venezuelan jungle. Over the last two months, she had shed nearly two stone, and was regularly burning up with ferocious temperatures.
‘I can tell you exactly what’s caused this,’ she said. ‘I’ve been bitten by a tropical spider.’
An eight-legged cause seemed surprising, but, when your patient has a PhD in ecodiversity, you hesitate to dispute their diagnosis, especially when it is as exotic and tantalising as this one. What doctor would not want to treat someone felled by a rampant tarantula? I settled down in front of my patient, eager to hear the full story.
After an exhausting day’s trekking, Dr Talbot and her husband had arrived back at their hotel eager to wash the dust and grime away. But, when she pulled off
her hiking boot, she found her sock to be soaked in fresh blood, with what appeared to be a puncture mark on the side of her foot. She had felt unwell ever since – shivery, nauseous and unusually weary. Red spots had slowly spread over both her feet and, by the time she returned to the UK, she had required a brief admission to hospital to treat with intravenous antibiotics what had become a florid foot infection. Now, she looked too thin and exhausted, clearly not a well woman. I was transfixed.
‘Once the infection was sorted,’ she told me, ‘I thought that was the end of the matter. But I just carried on feeling wretched. Some days I can’t get out of bed. My clothes are hanging off me. And, on a bad day, the sweats are appalling.’
‘Could a spider have managed to bite through a leather boot?’ I mused.
‘No. But it could have been hidden in the sock,’ she answered.
The visual image was irresistible. Nothing renews a passion for medicine like a good old-fashioned diagnostic conundrum. That night, I scoured the Internet for information on chronic illnesses triggered by tropical spider bites, even though I knew I was clutching at straws. The fact was, we had nothing else to go on. Aside from the persistent fevers and weight loss, Dr Talbot’s physical examination had yielded no clues. Her blood tests showed grumbling, chronic inflammation, but gave no indication of the underlying cause. Rogue infections, an occult cancer or some kind of autoimmune disease could all be driving her symptoms. So we hunted for hidden tumours with a top-to-toe CT scan, and ran endless blood test for weird and wonderful infections, but everything drew a blank. Meanwhile, our patient languished in her bed, becoming progressively thinner and weaker. If our medical detective work did not deliver soon, we feared for her future.
Eventually, we decided to carry out a specialised PET scan in which tiny amounts of radioactive glucose are injected into the blood, illuminating areas of the body that are particularly metabolically active due to cancer, infection or inflammation. The consensus, by this stage, was on a nasty hidden cancer, but we all hoped we were wrong. To my delight, the scan results confounded us. The great arteries of her body – the aorta, the carotids and the renal arteries – were ablaze with light, traversing the computer screen like comets. In their luminous traces, we had found our answer. The spider, in this case, was actually a red herring. Dr Talbot had a large-vessel vasculitis, a condition in which the blood vessels become inflamed and angry, often when the immune system turns upon itself, attacking healthy tissues. With a diagnosis, at last we had something to treat, and we started her immediately on powerful immunosuppressants.
This was NHS medicine at its best. A medical conundrum that piqued and intrigued even the most experienced of consultants. A patient and her family who were desperately fearful, needing all the support and sensitivity that we could muster. The expertise of three different specialist teams, all brought to bear on the case, plus state-of-the-art imaging and blood work. A diagnostic process not driven blindly, according to protocol, but using clinical acumen, lateral thinking and teamwork. A result – a diagnosis – derived as quickly as any gleaming private institution could offer, despite the dilapidation and quaint mid-century shabbiness of the ward. Too often in these straitened times, the NHS falls short of excellence, but when the system works well, as on this occasion, it can still be second to none. Not only did Dr Talbot rekindle a flicker of my old love of medicine, she restored a glimmer of my faith in the NHS as well. There were still successes, many of them, for all of us to feel proud of.
At the far end of the worktop where I stood writing in a set of notes, a telephone began to ring. The temptation to ignore it was almost irresistible. In answering a random hospital phone, you risk becoming embroiled in a complicated, lengthy conversation with someone you have no idea how to help, as your boss hovers grumpily over your shoulder, communicating through tuts and menacing stares his displeasure that you are not feverishly sorting out the patients currently swamping the A&E shop floor. It sounds profoundly selfish – these may be relatives of patients, distraught and anxious – but, when your workload means you sometimes go without eating, trying to help arbitrary callers as well as your patients is simply not always possible. This call was a case in point. A lab technician wanted to give me the result of a blood test for a patient I’d never heard of. I was already regretting picking up. Then the technician told me the result. The potassium level in the patient’s blood was 10.8, over twice as high as it should be.
‘It looks like someone printed out the result two hours ago, so I assume it’s already been dealt with it, but I thought I should check,’ she explained.
Her thoroughness was driven by awareness of the havoc a potassium of this order can wreak. The concentration of potassium in the blood is crucial in regulating the spread of electricity through the heart. Excessive potassium – hyperkalaemia – makes the heart wildly excitable, sending the electric flow haywire and potentially causing the heart to beat erratically or, in extreme cases, stop beating altogether – a cardiac arrest. I too assumed the result must have been dealt with from the simple fact that I could see on my computer screen that the patient was still alive, around the corner in resus. By rights, with potassium this high, I’d have expected her to be dead by now.
‘I’m sure it’s sorted, but I’ll go and check myself,’ I said, walking around to resus, intent on finding the patient and, crucially, on checking her cardiac monitor.
An ECG traces in graphical form the flow of electricity across the heart. Learning to interpret the meanings of its peaks and troughs, their dimensions, distortions and idiosyncrasies is a vital task to master at medical school. Elongated, oversized spikes, for example, suggest a likely diagnosis of longstanding high blood pressure. A heart attack may reveal itself through dramatic, convex bulges on the ECG trace – the ‘tombstone’ sign, as it is aptly known. In the case of potassium, as the level in the blood inexorably rises, so the patient’s ECG warps and contorts in an ever more distinctive pattern. After a little practice interpreting ECGs, even the most junior of medics should be able to spot severe hyperkalaemia instantly.
I found Mrs Mulligan’s electronic heart trace before I found the patient. It leaped out at me from her bedside monitor, screaming full-scale hyperkalaemic emergency. The chaotic trace was so bizarre it looked moments away from a cardiac arrest. Jarringly, the patient herself was in fine fettle, chatting away with the three or four family members assembled at her bedside, a piece of half-eaten toast in her hand. Often, hyperkalaemia is a silent killer. The patient is entirely symptom-free until their heart, without warning, suddenly stops beating. In this case, a nurse or doctor was nowhere to be seen and, worse, given how urgently I needed to protect the patient’s heart, there was no cannula in her arm for intravenous medication. I quickly found a nurse and furtively, out of earshot of the family, explained the situation.
‘Yes, it really is 10.8. No, no cannula. I’m going to get access now. Can you grab the calcium gluconate and we’ll get it into her as quickly as possible?’
Then, with what I hoped was soothing chitchat with the patient – that last thing I wanted was any adrenaline surges – I stuck a needle into her vein as swiftly as possible, to enable us to give the drugs that would help protect her heart. Mercifully, we were just in time. Shortly after that, Mrs Mulligan was rushed to Intensive Care for haemodialysis, the quickest way to remove the excess potassium from her blood. A random phone call, reluctantly answered, might just have saved her life.
Some months later, I was reminded of this case when one of the hospital’s haematology consultants stayed late into the evening – unpaid, unrewarded – to give a few of us, his juniors, some impromptu bedside teaching. A phone rang at the nurses’ station. No one else was there to answer it. While everyone in the group shifted uncomfortably and pretended to ignore it, Dr Fraser – Mark to patients and colleagues alike – leaned forward and picked up the receiver. ‘This is Mark Fraser speaking, how can I help?’ Afterwards, someone made a joke of it. ‘Never, ever pick
up a random phone – first rule of ward work.’ Mark looked up, quietly unamused. ‘Whose job is it to answer the phone on the ward?’ he asked, his question met with awkward silence. ‘It is everybody’s job. I always imagine how I would feel if there were a member of my family somewhere in a hospital, and I was calling to try to find someone who knew about them.’
This act, so small, spoke volumes. Almost never, in all my seven years of practice, have I seen another consultant pick up a randomly ringing telephone. They are invariably left for a more lowly staff member to deal with, as if, with seniority, you earn the right to ignore the low-grade irritations of the ward. But Mark, quite rightly, regarded each ringing phone as a potential relative in distress, needing our support and kindness. Since that evening, I have never left a phone unanswered.
Senior doctors infect their juniors with more than a wonder for medicine. They provide, through their example, a model of doctoring, be it good, indifferent or downright bad. Whether they realise it or not, their every move – a conversation with a patient, a tendency to disparage their colleagues, the particular way they lay their hands on an abdomen – is scrutinised and stored away by their students and juniors alike. The more inexperienced, the more like newly hatched goslings we are, latching onto whichever living creatures larger than ourselves we first encounter on the wards, imprinting our behaviours on theirs. If callous, consultants give senior permission for heartlessness, effectively handing out a licence to be cold. If kind, they teach their juniors that kindness is valuable – a trait to take seriously and nurture.
The first consultant who ever taught me at a patient’s bedside, a professor so erudite he is tipped for a Nobel prize one day, combined medical rigour with remarkable gentleness. I would watch, entranced, as, on meeting a patient on the ward, he enfolded their hands in both of his, seemingly in order to comfort and connect with them as he looked them in the eye and discussed their illness. In fact, with that simple human touch, he was simultaneously taking their pulse, assessing their hydration status, scanning their hands for clues of illness, and appraising whether they were sick or well. The patients, I suspect, thought he was just being kind. Actually, he was covertly diagnosing them. Hard, effective medicine cloaked in gentle humanity. I saw in him a model to emulate, something I have endeavoured to do ever since.
Your Life In My Hands--a Junior Doctor's Story Page 18