Breaking and Mending Read online

  It was a cream envelope with my name written on it.

  A card with pink and yellow flowers on the front and ‘thank you’ printed in gold. Joan’s sister had written inside:

  Joan thought the world of you, you know

  and, beneath the beautiful copperplate script, guided by her sister’s hand, and in shaky letters of uncertainty, Joan had managed to write her own name.

  I knew I would keep the card forever; even after Joan and her sister had long since disappeared and I, perhaps, sat on the edge of a bed somewhere myself, with my sloping shoulders and whorls of white ice-cream hair, because I would need that card as a reminder.

  A reminder that sometimes it is better to worry less about what your job might be and more about the tiny decisions we are able to make that will help someone else’s journey become a little bit easier.

  A reminder that our role in life isn’t always the most obvious one.

  Buried

  There are two things you always remember about being in hospital. The times you felt the most afraid and unsure, and the times when someone showed you a kindness.

  The patient

  As well as keeping Joan’s thank-you card, I also kept Joan.

  She travelled with me each day as I moved around the hospital. She accompanied me on ward rounds and we sat together in X-ray meetings. She ate lunch with me each day in the canteen and drove home at night next to me in the silence. She wasn’t alone, either. Others journeyed with me too. The thirty-eight-year-old father with pancreatic cancer. The woman knitting in the corner bed. The dying woman in the side room begging for morphine. The young man in ITU. Children in paediatrics with non-accidental injuries. The terminally ill woman in her twenties, whose identical twin sister visited the ward every day and reminded us all of the devastation of cancer. As each day passed, I collected more and more people, and it was inevitable that the weight of those people would prove too much to bear.

  The first thing I noticed was how slow I had become. It felt as though I carried the memory of these people in my legs, because each step took every ounce of energy. Unless it was an emergency, I didn’t rush anywhere, and it took me the longest time to walk from one end of the hospital to the other. A porter told me that each time he passed me in the corridors, I was always staring at the floor and I realised he was right. I had stopped looking up.

  My brain became slower too. I doubted myself constantly. Whenever questions were raised on a ward round or in teaching, I couldn’t process what was being asked and I would always be the last to answer. I stared at my jobs list each day, unable to attempt anything on it because the sense of being overwhelmed was so great, so terrifying, it felt like a form of paralysis. If I did manage to complete something, I would return to check again and again and again that I had done it properly, and, if self-doubt is fed and watered by those around you it will soon begin to grow and flourish. On night shifts, whenever I had a few minutes to spare, I would sit in one of the empty offices and take patient notes down from the shelves. At first, it was only the patients belonging to our team, but it soon became any patient. Any department. It didn’t matter, as long as there was a story. I would read through each entry, right back to the referral letter, and ask myself whether I would have spotted something on the X-ray, or had the foresight to order a particular blood test. Did I have the intelligence to prescribe that medication or request a CT scan? Was I smart enough? Was I a good enough doctor? Did I deserve to be there?

  I became fixated on the risks of spreading infection, and in between patients I would stand at the sink and scrub until my hands became red raw, but still I wouldn’t stop, and soon my knuckles started to crack and bleed. One of the nurses noticed and gave me a tiny little pot of Sudocrem, and that small act of kindness in a sea of despair moved me so much that I went into the sluice room and I sobbed. I barely ate. I hardly slept. I lost vast amounts of weight. My hair was matted and stuck to my skull. I would crawl into bed each night and lie in the darkness, unpicking the day, and each morning I would crawl out of bed, dress in the clothes closest to my hands, and I would walk back into a life I had begun to think of as the worst possible living hell. The rest of the hospital coped. I watched other doctors march through their work with what seemed like the smallest of efforts. I walked only at the edges, treading carefully, and my goal each morning was to somehow arrive at the end of day without losing my mind.

  If you continue to walk at the edges, it doesn’t take long for others to notice. We are very good at spotting when someone isn’t pulling their weight, but less good at asking why that weight is no longer being pulled. We are also very good at confronting people about it, and several times, doctors who were younger and less experienced felt authorised to tell me off for not being somewhere they felt I should be, or not doing something they felt I should have done. Perhaps they were right, but none of them felt the need to question why that might be so.

  I had a small library of people I could visit whenever I felt dangerously unable to cope. Different nurses dotted around the hospital who were especially kind. The bereavement officer, who was one of the most compassionate people I had ever met. The sister on Ward 4, who once made my day by telling me I would have been a wonderful nurse. The hospital chaplain, who always stopped to speak to me and who had the wisest eyes of all. The chapel was right next door to the doctors’ mess and I would sit in there sometimes after a difficult shift, even though I had stopped being able to see any evidence of God at all as I walked those corridors. Perhaps it was the comfort of a silence after all the noise, or perhaps it was the chance that somewhere within that silence there lay the possibility that one day I would find Him again.

  I had arrived on the wards filled with joy and enthusiasm, and a desire to be the best doctor I could possibly be. The inadequacies of the system, the lack of funding, the absence of people to provide the necessary care, and the misery and the death and the dying had all whittled away at me until there was nothing of that doctor left. She was gone. Sometimes, she felt so far away, I began to wonder if she’d ever existed in the first place. I’d always walked an extra mile, even if I was never the best, but the job had sent me into such a deep well of despair that it took less energy to wear the coat they had now given me: outsider, troublemaker, clock-watcher. It was so very much easier to become that person than it was to swim against the tide.

  I had always looked up to the NHS. I had always seen it as a shelter, a constant, somewhere offering protection and safety to those in need, and yet its quiet and petty cruelties took my sense of loyalty and allegiance, and removed it, piece by piece. When my uncle died, I was required to provide a death certificate in order to take three hours off for the funeral. When heavy overnight snowfall prevented me from driving into work, I was forced to wade into the middle of my road, through knee-deep snow, to take a photograph in order to prove that I wasn’t lying; and I quickly found that, despite their name, human resources were not especially resourceful and actually contained very little humanity.

  The NHS I loved had turned its back on me. Not only had it allowed me to fall, there were times when it felt as though it had given me a small push in order to get me there.

  At the beginning, middle and end of a placement, you are expected to meet with your consultant to discuss your time there. Any issues you may have encountered. Any problems. To review your progress and discuss your learning, and to ensure that your spiritual and emotional well-being remain intact. These meetings are notoriously difficult to arrange, due to both the consultant’s heavy workload and the junior doctor’s endless list of jobs. You are expected to find someone to ‘hold your bleep’ for the duration of these meetings and very often the only thing you can think about for the whole time you are in there, is how much work is mounting up in your absence. Some consultants prioritise these meetings, some do not. Very often, the middle meeting is forgotten and glued to the final one in an attempt to preserve the impression that someone was concerned about you for thos
e four months.

  In surgery and medicine, these meetings often felt like a piece of theatre. You sit in front of a consultant, someone you barely know, someone who you’d frantically tried to keep up with on a ward round, someone who clearly coped very well in the job in which you are now struggling to survive, and the consultant you barely know asks you if you are okay. You weigh up your options. You see the cursor hover over a white box, ready to tick. You sit ashen-faced, with red-raw hands, exhausted, gaunt, yesterday’s sleep still sitting in the corners of your eyes, and with a paper-thin voice you tell him that you’re fine, absolutely fine, because ‘fine’ is so much easier than the alternative. Saying anything else would take too much energy, and you know that the small amount of energy that you possess needs to be saved. If you squander it on telling a complete stranger how you really feel, you are worried you might not have enough left in you to make it to the other side of the day.

  ‘I’m fine,’ you say. ‘I’m absolutely fine.’

  But fine is a word that will slide from your throat, and fine is a word that will bury you.

  In my placement in general medicine, I sat in front of a respiratory consultant and I was asked this question. He leaned forward as he asked, and for a moment I thought he was going to rescue me. I thought I had finally been noticed. Instead, he listed my inadequacies one by one, carefully dismantling the very last pieces of my self-belief, reducing me to nothing, and he screamed all of this at me with such violence that his spit landed in my face.

  After he’d left, a secretary came rushing from an office three doors down, to check that I was okay. She stood in the doorway and looked at me with a curious tilt of the head.

  There was more concern in her face than I had seen from anyone in that hospital for the last twelve months.

  ‘I’m fine,’ I said. ‘I’m absolutely fine.’

  Birthstones

  There are times I may have been the doctor I did not want to be. I have to accept that it was me who ignored a patient telling me he did not want to be alive during a busy surgical ward round because I did not know what to do with it, that it was me who ignored the distress of a colleague falling ill. It was me and not someone else. Just me. The doctor I did not want to be. When I ask myself these questions, over and over, and think of the possible answers, the self-compassion I told others to apply to themselves has provided forgiveness for some of my shortcomings.

  The consultant

  Burnout is an unlikely phrase, because it implies that the effects are loud and obvious, raging like a fire for everyone to see.

  Most burnout, however, is quiet and remains unseen. It exists behind a still and mirrored surface, deep, out of reach, unnoticed by everyone – even, sometimes, by the one who is burning. You might catch a glimpse of it if you look carefully. You may say that someone is acting out of character or is unusually short-tempered. You may curse a co-worker for constantly missing deadlines or for being too easily distracted. You may notice that someone is always very early (or always very late) and you may detect that they have a lack of interest in the work in which they once took pride. Or you may notice none of these things. You may walk alongside a raging fire, day after day, without seeing even a trace of its existence, until a time when something happens and the flames can no longer be kept under control.

  Gill was a patient in a side room on Ward 8. We were the same age, almost to the day.

  As children, we’d watched the same television shows and saved our pocket money to buy the same records. We had grown up with the same posters pinned to our bedroom walls and we knew all the same lyrics to all the same songs. The only difference between Gill and me was that Gill had metastatic breast cancer and I did not.

  On the ward round, I would stand by Gill’s bed in the side room and write in the notes as the consultant spoke. As I wrote, I would think about all the past birthdays and past Christmases. How we each had marked our lives with the same tape measure, and how we had both assumed the same guarantee. I thought about all the lyrics to the songs, and as I looked across at her, it felt as though I was staring into a mirror. The reflection in that mirror was almost unbearable, but I had to keep looking. I needed to find another difference between us, because, if I didn’t, I was worried I would never be able to turn away.

  Gill had been in hospital many times over the past few years. With each visit, the entries in her notes became shorter and shorter, and the hope became less and less. We were now at the point where the only outcome of Gill’s treatment would be to prolong her life by just a small amount. We were also at the point where the small amount of life she had left would be ruined by the very same medication that delivered her that time. It’s a decision many terminally ill patients will inevitably face. Quality or quantity. To live by clocks and watches or to turn away from them and find another measurement. It is not for you or I, or any doctor or nurse, to say what we would or wouldn’t do in that situation: it’s always up to the patient to make that decision by themselves. When I walked into Gill’s side room late one afternoon in November, I knew immediately that a decision had been reached.

  I had been called to reinsert a cannula. The old one had failed and needed to be changed. Gill lay in the semi-darkness, exhausted from treatment that made her sick and weak, that made her too drained to lift her head or to bear even the tiniest fraction of light from the window upon her face.

  I removed the old cannula and, on a blue sheet, I laid out the equipment for its replacement. Swabs and gauze, syringes, water, tape and bottles. As clinical and sterile as it seems, taking blood or inserting a cannula is such a personal, intimate act, because the first thing you do is to search for a vein, and in order to do that you need to hold the patient’s hand. The times I have taken the hand of an elderly, lonely patient and held it in mine to look for a vein, and they have immediately squeezed my hand back in return.

  I held Gill’s hand and looked at the tired, worn veins for a possible candidate. I even checked the vein just below the thumb, affectionately known as ‘The Houseman’s Friend’. There was nothing.

  ‘You don’t need to find a vein,’ she said.

  I looked up. Her face was as pale as the pillow, and she was so frail it seemed as though she was slowly disappearing into the bed. There are terms used in cancer, for example sarcopenia and cachexia – the wasting away of lean tissue and muscle mass – but there is also a certain look you can spot in someone who is terminally ill. It doesn’t have a textbook name or an official definition, but to someone who has walked the wards for long enough it’s unmistakeable. It’s a look that tells you this person does not have very long left. Gill had that look.

  ‘I don’t want another cannula,’ she said. ‘I’ve had enough.’

  It was discussed with the consultant and the Macmillan nurse, and with Gill’s elderly parents, who were never very far away. It was agreed and decided. There were tears and sadness, but also, it seemed, a strange sense of liberation, as if Gill had finally taken back the reins. Cancer makes so many decisions for you, it must be empowering – even in those distressing circumstances – to make a decision for yourself.

  I was on a set of nights that week, and the first thing I did before my shift began was to visit Gill and also her parents, who had set up home in the little side room – her mother on a pull-out bed and her father sleeping in an armchair. Sometimes they had a question about the medication that was keeping Gill comfortable, sometimes I think they just needed the presence of someone else in the room for a while, a reminder of life outside the hospital and a conversation about the mundane and the ordinary. A few minutes of escape. I would see them occasionally during the night, walking out anxiety and cramped joints along the long, silent corridors, and every evening when I arrived for my shift, I would expect to see Gill’s name missing from the list of patients. She held on. We waited.

  After my run of nights, I had a day before I was due on call. On the rota, that day looked like a day off, but in reality it was just twent
y-four hours in which to try to recalibrate and adjust your body clock to being awake in daylight again. Before I headed into A&E, I went to the ward and sat at one of the computers, and I’d just started scrolling through the patients waiting in the emergency department when Gill’s mum ran down the corridor to the nurses’ station.

  ‘Could you come now,’ she said. ‘Gill’s breathing has gone funny.’

  If you have ever sat with someone at the end of their life, you will know what Gill’s mum was hearing. Textbooks try to describe this kind of breathing. They give it a name and attempt to analyse it, but you can’t imagine its distinctive sound until you witness it for yourself.

  I looked at Gill. She lay back with her eyes closed and her face was ironed of all the agony and the pain she had been through. She was more relaxed than I had ever seen her before and, in those moments, I saw a glimpse of what Gill was like before the cancer. When she was just Gill.

  ‘I don’t think it will be very long now.’ I turned to her parents. They looked small and broken. ‘Would you like me to sit with you?’

  I didn’t think for a moment they would say yes.

  ‘That would be lovely, Jo,’ said Gill’s mother. ‘If you wouldn’t mind?’

  Of course I didn’t mind.

  Her parents sat either side of the bed, and I put my bleep on silent and stayed on a plastic chair against the far wall. The windows of the side room looked on to a little path that led to the staff entrance of the hospital, and I could hear footsteps beyond the drawn blinds. Everyday chatter. Laughter. Clocks that hadn’t stopped.

  Over the top of this was Gill’s breathing. Slowing. Leaving.

  Gill’s mother looked at me. ‘I don’t know what to talk about,’ she said.

  ‘Why don’t you talk about Gill before the illness?’ I replied. ‘Things that made her laugh, adventures you had together, what she was like as a child. Then the last thing she’ll hear is happy memories.’