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

by Rachel Clarke

  Mark Fraser, the only consultant willing to answer random phone calls to the ward, once broke all the rules at the bedside when he saw in an instant that his patient needed an approach that transcended rigid Trust protocol. We were almost at the end of our morning ward round, having deliberately saved seeing Alice Fitzpatrick until last. Mrs Fitzpatrick had been recently diagnosed with a particularly aggressive form of acute leukaemia that had not responded to chemotherapy. In an effort to tame her virulently multiplying cancerous blood cells, she had just undergone a bone-marrow transplant. After almighty doses of cancer-killing drugs, two things needed to happen. First, the cancer needed to be gone – obliterated by the chemical onslaught – second, the bone marrow from her unknown donor needed to have successfully engrafted within her bones. But our daily blood tests suggested otherwise. The marrow was empty, a factory that had ground to a halt.

  Severely anaemic, and vulnerable to overwhelming infection and bleeding, she was propped up with blood transfusions day after day, waiting for the time when she would start, or so we hoped, producing her own blood cells. Eventually, with no sign of that happening, a haematologist took a sample of her bone marrow to scrutinise under a microscope in an attempt to deduce what the problem was. That morning, we had discovered the answer. The cancerous cells of old were back, still present, still multiplying in defiance of the strongest poisons we had hurled their way. Her future was bleak and it was Mark’s unenviable task to tell her this.

  I remember every moment. His voice, combining compassion with quiet authority, stating the facts clearly and calmly, with no ambiguity. Her face, folding in on itself with the weight of grief and fear, thin shoulders heaving beneath a wall of pinned cards from her friends and children, talismans against an unknown future. Her head bowed down to her chest, its baldness defiantly wrapped in an expensive, primary-coloured scarf. She knew, at that moment, that the hope she had nursed and coaxed through every twist of her journey was now at the point of being snuffed out. Words were not going to touch her. She needed something more primal for comfort. Ignoring the diktats of ‘infection control’ and, no doubt, further regulations about appropriate behaviour with the opposite sex, Mark sat himself down beside his patient, both of them perched on the edge of her bed. Tenderly, he placed his arm around her shoulders and she laid her brow on his chest. Her tears dripped onto his shirt as he quietly rested his head upon hers. They sat that way for some time, saying nothing. I was struck by how sometimes, the interaction between a patient and their doctor – each thrown together only briefly and by chance – looks less like a job than an act of love. This was one such occasion. Later, I wondered how much of himself Dr Fraser had needed to give – how much, in the end, providing solace of this kind ends up taking from a person.

  Like the hundreds of doctors who have taught me on the job – usually at their own expense, working longer, later or harder for nothing but the reward of freely imparting their knowledge and skills – I was eager to teach as soon as I knew anything worth teaching. I always smile ruefully when the Department of Health press office pushes outlandish figures that purport to show the cost of training an NHS doctor from scratch. An eye-watering figure of £230,000 for medical school alone is their current favourite.59 Yet, for the vast majority of our time as doctors-in-training, we are not being trained: we are ‘delivering the service’ – churning through job after job, patient after patient, with our ‘training needs’ hovering somewhere between an inconvenience and an afterthought. It is individual doctors who have taught me what I know – and at zero cost to the taxpayer, since they have done so in their own time, as impromptu pedagogues, invariably unsupported by their employer.

  Just before medical school finals, hospitals turn into stalking grounds for paranoid students desperate to find patients with the unusual clinical signs that might floor them in their looming exams. As doctors, we have to strike a balance between protecting our patients from the unwelcome intrusions of too many exam-crazed students and trying to help them learn. Each disease has its own constellation of physical signs – lumps to feel, heart murmurs to hear, rashes to spot and other oddities – provided the student is sufficiently skilled to elicit them. The rarer the signs, the more alluring the patient. If word gets out that a patient is lurking with exceptionally unusual examination findings, students may flock to their ward in hordes, sometimes requiring us to ban them from the bedside if that is what the patient would prefer.

  Once, a friend gave me a precious tip-off. ‘Promise you won’t pass this on to anyone else, Rach, but I have a patient with situs inversus in bed 10. He’s happy for one group of students to examine him.’ As soon as I could escape the ward, I ran upstairs to find the patient. He was, indeed, willing to meet my small group of students. Before leaving, I could not resist asking permission to listen quickly to his chest myself. Like every medical rarity until the moment you first encounter it, situs inversus was mythical to me, about as plausible as a unicorn strolling down my ward. A rare idiosyncrasy of embryonic development, it arises when all the major organs develop on the opposite side of the body to the usual. In a mirror image of normal, the heart sits on the right-hand side of the chest, a condition known as dextrocardia.

  I placed my stethoscope over where I would expect to find the loudest heartbeat and heard … precisely nothing at all. No hint of a heart on the left side of the chest. It was the most delicious silence I have ever heard. And then – on the right – a healthy, normal, beating heart ringing loud and clear through my stethoscope. So wrong – like a violation of nature – and so miraculous that this was just a variant of natural, one that one in ten thousand people happened to possess. I messaged my students to join me on the ward at the end of the day to meet a patient they would never forget.

  Mr Hodges, the patient, grinned magnanimously as each student listened to his heart and tried to describe their findings. None of them could quite bring themselves to confess they had heard nothing at all. ‘Very quiet heart sounds,’ commented one of them. ‘But – um – I think there may have been a quiet murmur of aortic regurgitation present too.’ Alas, he had fallen at the first hurdle of bedside teaching: never make up your findings. Eventually, Mr Hodges waded in to help. ‘Why would my heart sounds be so quiet?’ he asked them. Suddenly, a light flickered across one student’s face. ‘Please may I listen to your heart again?’ she asked him. This time, her stethoscope went straight to the far side of his chest and, as she placed it over the apex of his heart, just below his right nipple, she gasped with audible delight and astonishment. Now the rest of the students were twitching with excitement. The diagnosis had dawned upon all of them and sheer wonder lit up the group. Mr Hodges must have seen it a hundred times before but still he smiled effusively.

  ‘Thank you so much,’ I said to him as we left. ‘You’ve just made their term – and mine.’

  At the heart of good medical training are the thousands of everyday encounters with senior doctors that cumulatively shape a junior’s practice. Formal training, the scant hour a week in which I am officially permitted to surrender my bleep to enable my attendance, may sometimes be useful but it is not a patch on the real, lived apprenticeship in doctoring I receive on the job thanks to my senior colleagues’ goodwill and their indefatigable impulse to pass on what they have learned. It is these relationships that are the bedrock of everything important that I know – and they rely upon sufficient time spent working together as a team that we inspire, encourage and motivate each other.

  Huge numbers of doctors love nothing more than to teach. Some of the senior ranks of the NHS, wringing their hands at what to do about all-pervasive despair among frontline staff, are missing a trick, because there is nothing quite like seeing our subject through a student’s eyes, aglow with enthusiasm, for reigniting our own passion for medicine. To lift the spirits and boost flagging morale, giving one good tutorial is worth more than a thousand Zumba classes. But time is the crux of the matter. Without time, with workloads so punitive
that doctors struggle to claw their way through them, a luxury such as teaching others – no matter how personally fulfilling and how vitally important for the future of the NHS at large – becomes impossible to sustain.

  There is, in short, much that is endangered in the complex, fragile, extraordinary ecosystem of kinship, affection, respect and goodwill that inspires individual doctors to teach and train each other. Without the time and continuity to build relationships with fellow doctors, these qualities – so important and sustaining within the profession – face extinction. I am reminded of Hector, Alan Bennett’s brilliantly idiosyncratic teacher from his play The History Boys, who captures the essence of teaching so beautifully:

  ‘Pass the parcel. That’s sometimes all you can do. Take it, feel it, and pass it on. Not for me, not for you, but for someone, somewhere, one day. Pass it on, boys. That’s the game I want you to learn. Pass it on.’60

  The word ‘doctor’ originates from the Latin ‘docere’ – to teach – and in my experience there is no better way of keeping the wonder and love of medicine alive than the endeavour to pass it on. But in an era of austerity, where every pound of Treasury expenditure must be rigorously justified, perhaps concepts as fluffy as wonder and goodwill are – just like kindness – entirely superfluous. After all, none can be counted. We cannot price up any of them. Yet the truth is, though these values cannot be bought and sold, they inspire the staff who drive the NHS more than any profit motive. And that – in an era of haemorrhaging staff, dwindling motivation, burnout and sickness at record highs – makes them priceless. If we wish to maintain a first-class health service, we squander them at our peril.

  CHAPTER 13

  CANDOUR

  ‘Hey. Any chance I could come round on my way home from work?’

  It was not like Sam, an old friend from medical school, to call me early one morning out of the blue. I had just dropped the children off at school and he had completed a night shift as a surgical registrar in his hospital. For all the feigned nonchalance in his voice, I could tell he needed to talk. An hour or so later, after a long, fraught motorway drive in which he struggled to keep his eyes open, Sam arrived at my house. I took one look at him and started brewing strong coffee.

  ‘What’s up? Was it a shift from hell?’

  It was the tail end of 2016. For months, the papers had been full of NHS horror stories. Maternity, paediatrics and A&E departments folding up and down the country due to lack of doctors. Patients stacked up for hours on trolleys in corridors since there was no space in A&E. Desperately sick babies being transported hundreds of miles to the only intensivecare beds available anywhere in the country, potentially endangering their lives. And then, a week before Christmas, the unprecedented news, leaked to the press, that a letter had been sent to every NHS Trust in England ordering it to suspend virtually all elective surgery for an entire month in an attempt to reduce dangerously high hospital bed occupancy rates. A month’s worth of surgery cancelled at a stroke – the misery for the hundreds of thousands of patients denied their operations did not bear thinking about.

  As the surgical registrar on call in his local hospital, Sam was responsible for all the surgical inpatients who became unwell overnight, plus any new patients arriving in A&E needing review by a surgeon. Not to mention the small matter of actually performing the emergency operations when required. Even at the best of times, emergency surgical nights are brutal. But this one was in a league of its own.

  ‘Do I blow the whistle, Rach? I mean, how bad do things have to be before you can’t stop yourself going to the GMC or the press?’

  ‘You can’t make any sensible decisions now,’ I counselled. ‘You’re too tired to think straight. You have to get some sleep first.’

  ‘You know exactly what happens to whistleblowers. You know I’d be destroyed.’

  The NHS has a long and grubby history of treating individuals who have tried to blow the whistle on unsafe practice with ruthless brutality, ruining careers and lives.

  ‘I know. I know what they’d do to you, Sam. But you have to get some rest, please.’

  The experience that had so traumatised my friend involved a young child. A&E had been in full-blown, early-hours meltdown. Patients and relatives occupied every available chair. Most had been waiting six hours just to see a doctor, let alone be treated or admitted into hospital. The drunks and the bigots were hurling abuse at the staff. Someone could not be stopped from screeching ‘Away in a Manger’ at a volume that could shatter glass. Many members of the public, seething with rage at the delays, were not holding back at the nurses. Amid all the ugliness and chaos of the Emergency Department, Sam had been asked to see an eight-year-old girl with abdominal pain. When he found her, Ayesha was flushed and whimpering, clutching her mother’s hand. Her pulse was racing, she was hot to touch and the pain in her abdomen was making her cry. She looked, in a word, ‘toxic’ – likely to be suffering a serious infection. Sam’s money was on appendicitis. The very high number of while cells in her blood also seemed to fit with infection.

  But something was not quite right. Her abdomen, when Sam had felt it, was completely soft to the touch. Ordinarily, when the abdominal cavity is severely infected, the overlying muscles of the abdominal wall are held completely rigid, clenched in an involuntary spasm. The unusual softness of Ayesha’s belly had held Sam back from taking her to theatre. Nobody wants to be the slash-happy surgeon who unnecessarily cuts open a child. But nor was a CT scan an option to aid the diagnosis since the radiation dose was too high for a young child, unless absolutely necessary. Sam decided to observe Ayesha for a short period, having started intravenous antibiotics, while teeing up the emergency theatre staff for a likely imminent surgery.

  All of this was routine stuff for a junior surgeon on call. What happened next was not. A besuited manager suddenly materialised to inform Sam that he was banned from taking the child to theatre since there were no beds into which she could be admitted afterwards. Not only that, he should never have admitted the child for fluids and antibiotics, given the lack of beds.

  ‘I’m sorry but I don’t think you appreciate the gravity of the situation,’ he explained calmly. ‘If she doesn’t pick up over the next hour with antibiotics, then I’m going to have to take her to theatre because there’s a good chance she will die if I don’t.’

  ‘No, you don’t understand,’ pressed the bed manager. ‘There are no beds, and I’m telling you that you will not be taking this patient to theatre. If you think they need surgery then it’s up to you to find a hospital somewhere else that will take them.’

  ‘But if there are no paediatric beds anywhere in the hospital,’ Sam pressed back, ‘then why on earth are you still allowing ambulances to bring sick children to A&E? That’s not safe. Why are you not on divert?’

  Hospitals that put out a ‘divert’ – effectively closing their doors to ambulances since they have run out of beds into which to admit patients – face large fines for doing so. Diverts are consequently loathed by the management, costing a Trust that is invariably in financial deficit from the outset even more money that it simply does not possess. In spite of all the other patients requiring his attention, Sam was forced to spend the next two hours frantically phoning every hospital in the vicinity trying to find one that would agree to admit his patient. But to no avail. Nowhere was willing to admit Ayesha because, like his own hospital, they too had no beds.

  ‘At this point,’ Sam told me, slumped on the sofa with his head in his hands, ‘it was all I could do not to burst into the A&E waiting room and yell to all the parents to get the hell out of the place and go somewhere that might actually be safe.’

  Increasingly concerned by the state of his patient, who by now had started to become delirious, he called his sleeping consultant at home.

  ‘I’m sorry for disturbing you, but I really need your expertise,’ he explained. ‘I don’t know what the right thing is to do.’

  Less than half an hour later, Sam’
s consultant was present in A&E, assessing Ayesha alongside his registrar. He had never seen a presentation of appendicitis quite like this one, he said, and agreed with Sam that, given how unwell the child now appeared, an exploratory operation was essential. ‘If we leave her much longer and she gets any sicker, she won’t survive the night.’

  At this point, the bed manager resurfaced. He repeated – to one of the most senior consultant surgeons in the hospital – that under no circumstances would Ayesha be permitted to go to theatre. ‘There isn’t a bed for her and that means no operation, end of story.’

  ‘But look,’ said the surgeon. ‘She’s in a bed now. A bed in a side room in A&E. She can come straight back here after theatre, can’t she?’

  ‘No, she can’t,’ insisted the bed manager. ‘This is an assessment bed, not an admission bed. It’s for assessing paediatric cases in A&E.’

  The surgeon paused before answering, working hard, one imagines, to frame a response that did not involve expletives. ‘If there are no paediatric beds in the hospital, then why are we still assessing paediatric patients in A&E? What exactly happens when the conclusion of the assessment is that we need to admit the child?’