This is Going to Hurt Page 3

  I confirm the patient’s identity from his hospital wristband, check visually for respiratory effort, check there’s no response to verbal or physical stimuli. Feel for a carotid pulse, check with a torch that pupils are fixed and dilated. Check watch and listen with stethoscope for heart sounds for two minutes. Then listen for lung sounds for another three minutes. Overkill feels like an inappropriate word, but five minutes is an extraordinarily long time when you’re standing motionless under brilliant white light, your stethoscope pressed against a definitely dead man’s chest, observed by his grieving wife. This is why we try and get them out of the room for this bit.

  I understand why we take the time to make sure – it’s kind of a deal-breaker with death.† The almost-widow keeps asking if I am OK – I don’t know whether she thinks I’m too upset to move or have just forgotten what to do next in the death-pronouncing – but every time she says something I leap up like . . . well, like a doctor hearing a noise while listening carefully to the chest of a corpse.

  Once I peel myself off the ceiling and compose myself, I confirm the sad news to her and document my findings. It was certainly an agonizing five minutes, but if the whole medicine thing goes tits-up, I’m only a tin of silver Dulux and an old crate away from a gig in Covent Garden as a ‘living statue’.

  * Doctors are legally obliged to fill out death certificates for their patients, detailing causes of death. In hospital settings they will generally also be asked to formally pronounce (confirm) death.

  † When a Pope dies, zero chances are taken. According to the Vatican’s rules, clearly drawn up by someone who thought The Exorcist was on the tame side, the doctor has to call out the Pope’s name three times, check the body’s breath doesn’t blow out a candle, then, just to be certain, bop him on the head with a hammer. At least she didn’t have to watch me do that.

  Tuesday, 5 July 2005

  Trying to work out a seventy-year-old lady’s alcohol consumption to record in the notes. I’ve established that wine is her poison.

  Me: ‘And how much wine do you drink per day, would you say?’

  Patient: ‘About three bottles on a good day.’

  Me: ‘OK . . . And on a bad day?’

  Patient: ‘On a bad day I only manage one.’

  Thursday, 7 July 2005

  Terrorist atrocities across London, major incident declared, all doctors told to report to A&E.

  My responsibility was to go round the surgical wards and discharge any patient whose life or limb wasn’t in immediate danger, to clear the decks for new arrivals from the bombings. I was like a snowplough with a stethoscope – booting out anyone who got to the third syllable of ‘malingerer’ without passing out or coughing up blood. Got rid of hundreds of the bed-blocking fuckers.

  Wednesday, 13 July 2005

  The hospital didn’t receive any casualties, and with no patients I’ve basically done no work for a week.

  Saturday, 23 July 2005

  This weekend is my best mate Ron’s stag do, and I’ve had to bail out with barely four hours’ notice. It’s annoying for a million reasons, from the fact it was just a close selection of pals with only eight of us making the cut, to the personalized T-shirts, to the now-uneven paintballing teams, to the fact I spent four hundred fucking pounds on it.

  I was originally due to be working, but arranged a four-way swap (A doing my shift, B doing A’s shift, C doing B’s shift and me doing C’s shift) – so it was always slightly precarious, like a house purchase in a massive chain. And now C (who I’ve barely met before) has real or imaginary childcare issues for one of her real or imaginary children, so I’m here on the ward instead of Zorbing, off my tits on tequila.

  Non-medics* struggle to understand it doesn’t actually help having loads of notice for this kind of thing: more than two months’ notice means we don’t have the rota yet. I order a bottle of whisky I can’t afford – I can virtually hear Elton John saying ‘Steady on, let’s not go crazy here’ – and arrange to have it delivered to Ron’s flat on his return, alongside my grovelling apologies. We arrange a stag-do postscript for just the two of us in a fortnight’s time – after my run of nights, and after the three locum shifts I booked in to cover the cost of the weekend I’m now missing.

  * There should be a term for non-medics, the medical equivalent of ‘lay person’ or ‘civilian’. Patients, maybe?

  Friday, 29 July 2005

  I spend the entire night shift feeling like water is gushing into the hull of my boat and the only thing on hand to bail it out with is a Sylvanian Family rabbit’s contact lens.

  Everything I’m bleeped about takes at least fifteen minutes to firefight, and I’m getting called about a new blaze every five minutes, so the sums don’t quite add up. My SHO and registrar are tied up in a busy A&E, so I prioritize the sickest-sounding patients and manage the expectations of the nurses who call me about anything else.

  ‘I’m really sorry but I’ve got a load of patients who are much more urgent,’ I say. ‘Realistically, it’ll be about six hours.’ Some understand and some react like I’ve just said, ‘Fuck off, I’m in the middle of an Ally McBeal boxset binge.’ I run from chest pain to sepsis to atrial fibrillation to acute asthma all night, like some kind of medical decathlon, and somehow everyone gets through it alive.

  At 8 a.m. one of the night sisters bleeps to tell me I did really well tonight and she thinks I’m a good little doctor. I’m willing to overlook the fact that ‘good little doctor’ sounds like an Enid Blyton character, because I’m pretty sure it’s the first time I’ve had anything approaching a compliment since I qualified. I don’t really know what to say but stutter my thanks. In my confusion, I accidentally sign off with, ‘Love you, bye.’ It’s partly out of exhaustion, partly my brain misfiring because H is normally the only person who says nice things to me, and partly because, in that moment, I genuinely loved her for saying that.

  2

  Senior House Officer – Post One

  By August 2005, I was a senior house officer. I was obviously still extremely junior, having only been a doctor for twelve months, but the word ‘senior’ had now been chucked into my job title. This was presumably to give patients a bit of confidence in the twenty-five-year-old about to take a scalpel to their abdomen. It was also the little morale boost I needed to stop myself jumping off the hospital roof when I first saw my new rota. It would be pushing it to call it a promotion, though – it happens automatically after a year as a house officer, much like when you get a star on your McDonald’s badge. Though I suspect Ronald pays better than NHS trusts do.*

  I believe it’s technically possible to fail the house officer year and be required to repeat it, but I’ve never actually heard of that happening. By way of context, I count among my friends a house officer who slept with a patient in an on-call room, and another who got distracted and prescribed penicillin instead of paracetamol to a patient with a penicillin allergy. They both sailed through it, so Christ knows what you have to do to actually fail.

  Senior house officer is the point at which you decide what to specialize in. If you choose general practice, you remain in hospital for a couple of years, doing things like A&E, general medicine and paediatrics, before moving to the community and being awarded your elbow patches and permanently raised eyebrow. If you choose hospital medicine, there are plenty of different roads you can stumble blindly down. If you fancy yourself as a surgeon, you can sign up to anything from colorectal surgery to cardiothoracics, neurosurgery to orthopaedics. (Orthopaedics is basically reserved for the med school’s rugby team – it’s barely more than sawing and nailing – and I suspect they don’t ‘sign up’ for it so much as dip their hand in ink and provide a palm print.)

  There are the various branches of general medicine if you don’t like getting dirt under your nails, such as geriatrics,† cardiology, respiratory or dermatology (which can be a revolting but relatively easy life – you can count the number of times you’d be woken up for a dermatolo
gical emergency on the fingers of one scaly, flaky hand). Plus there’s a bunch of specialities that aren’t quite medicine or surgery, like anaesthetics, radiology or obstetrics and gynaecology.

  I chose obs and gynae – or ‘brats and twats’ as it was charmingly known at my medical school. I’d done my BSc thesis in the field, so I had a little bit of a head start, so long as people only asked me questions about early neonatal outcome in the children of mothers with antiphospholipid syndrome, which somehow they never did. I liked that in obstetrics you end up with twice the number of patients you started with, which is an unusually good batting average compared to other specialties. (I’m looking at you, geriatrics.) I also remembered being told by one of the registrars during my student placement that he’d chosen obs and gynae because it was easy. ‘Labour ward is literally four things: caesareans, forceps, ventouse and sewing up the mess you’ve made.’‡

  I also liked the fact that it was a blend of medicine and surgery – my house officer jobs had proved I shouldn’t really be majoring in either. It would give me a chance to work in infertility clinics and labour wards – what could be a better, more rewarding use of my training than delivering babies and helping couples who couldn’t otherwise have them? Of course, the job would be difficult emotionally when things went wrong – not every stork has a happy landing – but unfortunately the depth of the lows is the price you pay for the height of the highs.

  There was also the fact that I’d ruled out every other speciality in quick succession. Too depressing. Too difficult. Too boring. Too revolting. Obs and gynae was the only one that excited me, a career I could genuinely look forward to.

  In the event, it took me months to actually make up my mind, commit and apply. I think the reason I hesitated was that I hadn’t made any significant life decisions since I chose which medical school to go to at the age of eighteen – and even that was mostly because I was impressed with the curly fries in the students’ union. Age twenty-five was the first point I actually got to make an active decision in the Choose Your Own Adventure book of my life. I not only had to learn how to make a decision, but also ensure I made the right one.

  You decide to pick up the forceps. Turn here.

  * My hourly rate as a first year SHO worked out as £6.60. It’s slightly more than McDonald’s till staff get, though significantly less than a shift supervisor.

  † Geriatrics is now known as ‘care of the elderly’. Presumably they want it to sound less clinical – less like a place where someone might actually expire, and more like a luxury spa where you can get a mani-pedi while drinking something bright green from a smoothie-maker. Some hospitals have rebranded the speciality ‘care of the older patient’ or ‘care of the older person’ – I would suggest the more appropriate ‘care of the inevitable’.

  ‡ About a quarter of babies in the UK are delivered by caesarean section. Some are planned (elective) procedures for things like twins, breech babies or previous caesareans. The rest are unplanned (emer-gency) caesareans for failure to progress in labour, fetal distress and various other crises. If the baby gets stuck or distressed in the final furlong of a vaginal delivery then you perform an ‘instrumental delivery’ using either forceps – metal salad servers – or a ventouse, which is a suction cup attached to a vacuum cleaner. I wish I could say those descriptions were an exaggeration.

  Monday, 8 August 2005

  First week working on labour ward. Called in by the midwife because patient DH was feeling unwell shortly after delivering a healthy baby. Nobody likes a clever dick, but it didn’t take Columbo, Jessica Fletcher and the entire occupancy of 221b Baker Street to work out the patient was probably ‘feeling unwell’ because of the litres of blood cascading unnoticed out of her vagina. I pressed the emergency buzzer, hoped someone a bit more useful would appear and unconvincingly reassured the patient that everything was going to be fine, while she continued to redecorate my legs with her blood volume.

  The senior registrar ran in, performed a PV* and removed a piece of placenta that was causing the issue.† Once it was coaxed out, and the patient had a few units of blood replaced, she was absolutely fine.

  I went to the changing rooms to get myself some fresh scrub trousers. It’s the third time in a week my boxers have been soaked in someone else’s blood and I’ve had no option but to chuck them away and continue the shift commando. At £15 a pop for CKs I think I’m running my job at a loss.

  This time it had soaked through further than usual and I found myself washing blood off my cock. I’m not sure which is worse: the realization I could have caught HIV or the knowledge that none of my friends would ever believe this is how I got it.

  * PV is a per vagina examination. PR is a per rectum examination, so do always clarify when somebody tells you they work in PR.

  † If there’s anything left in the uterus after delivery – placenta, amniotic membranes, a Lego Darth Vader – the uterus can’t contract back down properly, and this causes bleeding until the offending item is removed.

  Saturday, 27 August 2005

  Accosted by a house officer to come and take a look at a post-surgical patient who hasn’t passed urine in the last nine hours.* I tell the house officer that I haven’t passed urine in the last eleven hours because of people like him wasting my time. His face crumples like a crisp packet in a fat kid’s fist and I instantly feel terrible for being mean to him – that was me a few months ago. I slink off to review the patient. The patient indeed has no urine output, but that’s because the tubing from her catheter is trapped under the wheel of her bed and her bladder is the size of a space hopper. I stop feeling terrible.

  * Doctors are obsessed with urine output – though not in the kind of way that would make you rethink going on a second date with them – it’s how you tell if the patient has a low blood volume. This is particularly bad after surgery as it could mean they’re bleeding somewhere or that their kidneys are rogered, neither of which are great.

  Monday, 19 September 2005

  First ventouse delivery. I suddenly feel like an obstetrician – it’s a pretty notional job title until you can, you know, actually extract a baby. My registrar, Lily, talks me through it gently, but I do it all myself and it feels fucking great.

  ‘Congratulations, you did amazingly well there,’ says Lily.

  ‘Thank you!’ I reply, then realize she’s actually talking to the mum.

  Wednesday, 21 September 2005

  Signing a stack of letters to GPs after gynae clinic when Ernie, one of the registrars – arrogant but funny with it – strides in to borrow an examination lamp. He peers over my shoulder. ‘You’re going to get struck off if you write that. Change it to “pus-like” or put a hyphen in there somewhere.’

  I look down at the offending phrase. ‘She has a pussy discharge.’*

  * At my next hospital, the gynaecology ward was right next to the holding area they put patients in to await transport home, and the sign on the wall said,

  GYNAECOLOGY WARD

  DISCHARGE LOUNGE

  Wednesday, 16 November 2005

  I glance at the notes before reviewing an elderly gynae patient on the ward round.

  Good news: physio have finally been to see her.

  Bad news: the entry reads, ‘Patient too drowsy to assess.’

  I pop in. The patient is dead.

  Tuesday, 22 November 2005

  I’ve assisted registrars and consultants in fifteen caesareans now. On three or four occasions they’ve offered to let me operate while they teach me the steps, but on every occasion I’ve wimped out – I’m now the only SHO of the new cohort not to have lost my virginity, as Ernie is so keen on putting it.

  Ernie doesn’t give me any option today – he introduces me to the patient as the surgeon who’s going to deliver her baby. And so I do. Cherry well and truly popped, and with a live audience. I cut through human skin for the first time, open up a uterus for the first time and deliver a baby abdominally for the first time. I’d
like to say it was an amazing experience, but I was concentrating far too hard on every step to actually take any of it in.

  The caesarean takes a laborious fifty-five minutes* from start to end, and Ernie is remarkably patient with me. As I clean up the wound afterwards, he points out that my incision was on the wonk by about ten degrees. He says to the patient, ‘You’ll notice when you take the dressing off that we had to go in at a bit of an angle,’ which she somehow seems to accept without question – the miracle of motherhood sugaring that particular pill.

  Ernie shows me how to write up the operation notes and debriefs me over coffee, stretching his virginity metaphor to within an inch of its life like he’s some kind of sex pervert. Apparently, with practice my technique will improve, it’ll get less bloody and less nerve-wracking, and eventually it’ll all just start feeling like a boring routine. The anaesthetist chips in: ‘I wouldn’t try and make your performance last any longer though.’

  * An uncomplicated caesarean should only take twenty to twenty-five minutes, with the wind in the right direction.

  Thursday, 22 December 2005

  Clinical incident. Bleeped at 2 a.m. and asked to review a gynaecology inpatient who was unconscious. I suggest to the nurse that most people are unconscious at 2 a.m., but she is still extremely keen that I attend urgently. The patient’s GCS* is 14/15, so ‘unconscious’ is rather pushing it, but she is disorientated and clearly hypoglycaemic. A nurse traipses off to find a blood glucose monitor for me from another ward. I’m fairly confident of my diagnosis so decide not to wait, and ask for the bottle of orange squash we keep handy in the clinical fridge for this situation. The patient drinks it but remains drowsy. It’s a bit late at night to be playing House, but I order some other tests and try to work out what else could be going on, as we wait for the machine to arrive. There’s never one to hand, even though they’re required all the time and cost about a tenner in Boots. I was thinking about just buying my own one, but it feels like a slippery slope that ends with keeping an X-ray machine in the back of the car.