Breaking and Mending Read online

  I’m not sure when it happened, or why, or even how, but at some point during those first few minutes of being in the mortuary, I let go of the shock and the fear. They disappeared somewhere, evaporated into the miracle of what I was witnessing – the miracle of anatomy and physiology, the miracle of the human body, and with each stage of the post-mortem, more small miracles were revealed and more diagrams came to life. When we reached the heart, and the left ventricle was pointed out to me, the sense of excitement was quite extraordinary. There was the left ventricle! The thing I had stared at in a textbook for the past few weeks was right before my eyes! It felt as though I had stumbled upon a celebrity.

  The very greatest miracle of all was left until last. As the brain was lifted out and passed to me, I realised that I held in my hands the very essence of who this person was. Their thoughts, hopes, dreams, worries. Their personality. Their sense of self. A lifetime of memories. All of those things rested on my fingers and for a moment, the privilege of what I was doing took my breath away.

  When the brain is dissected, you will find, lying deep within the cerebellum (the ‘little brain’) an area concerned with transporting motor and sensory information. It looks like a series of delicate branches or the fronds of a fern, stretching its tiny fingers out deep within our minds. It helps us to negotiate the landscape, to make sense of what’s around us. To survive. It’s called the arbor vitae, or the tree of life, and it remains one of the most beautiful things I have ever seen.

  After that day, I became a regular at the mortuary. I was on first-name terms with the attendants. I didn’t need to check the pieces of paper in my pocket in order to press numbers and letters into a silver keyboard, and I no longer became trapped within corridors. I even had a need for my wellington boots and my elbow-length gloves.

  Of course, I still went to the dissection room, which no longer held any fear for me at all, and I would enjoy staring down a microscope at the many towns and villages that lie deep within our bodies. But the mortuary seemed more real, more relevant. Whenever I left, I would move back along the corridors, past the secretaries typing letters and the people carrying mugs of coffee, further and further towards an everyday life, and I would emerge through the little unmarked door at the reception desk. On each occasion, I would walk back to my car, passing crowds of people living their ordinary lives, and I would think ‘you have no idea what I have just seen’.

  On the way home, I would study everyone around me – a cyclist at a set of traffic lights or people making their way across a pedestrian crossing – and I would imagine all the anatomy that lay beneath their flesh. All those small miracles. I became slightly concerned about myself as I began to wonder if I would ever again view human beings in the same light. I decided I would visit the mortuary one more time. I had other subjects to learn about and it had served its purpose. It had helped me to face the thing that had terrified me the most, and the rest of medical school would be plain sailing.

  I was deeply naïve.

  On my last visit to a post-mortem, I arrived in the changing room to find my registrar standing in front of the double doors, blocking my way into the tiled room with the three stainless steel tables.

  ‘I was going to text you,’ she said.

  I thought there’d been a change of plan. Perhaps she had to be somewhere else. Perhaps there were no dead people that day.

  ‘Is it cancelled?’ I said.

  ‘No.’ She shook her head. ‘It’s not cancelled. I just wanted to give you the choice.’

  I frowned.

  ‘It’s a suicide,’ she said. ‘Do you still want to be here?’

  I looked beyond her, towards the double doors, and I wondered what lay behind them.

  ‘I still want to be here,’ I said.

  It was a man.

  The two other tables were empty, and he was alone. He’d failed to turn up at a prearranged appointment and his daughter had gone to her childhood home to find that her father had hanged himself in the garden shed. He was fifty-three. There had been no warning. No prologue to the story. No indication he had decided to take his own life, because you will never spot the suicide who does not want to be seen. The daughter somehow managed to cut him down, and she performed CPR with such desperation, such anguish, that she broke every bone in her father’s ribcage. I stared at his face and at the ligature mark around his neck.

  We began.

  Afterwards, my registrar disappeared briefly to collect something and, for the first time, I was left alone. While we’d been working, someone else had been brought in. It was also a man and he waited for us on one of the other tables. I walked over and looked at the whiteboard on the wall above his head, where the attendants wrote any information they had been given. This man was also fifty-three, and he’d been killed that morning in a car accident. I walked back to my table. Again, I looked across at the other man.

  If you had asked me prior to that moment about my views on suicide, I would have told you how much compassion I had towards someone who had been so desperate they had felt compelled to take their own life. I would have told you how much understanding we should all try to find and how we should never judge someone unless we have walked alongside them on their journey. Yet, standing in that mortuary between those two tables, I was filled with so much rage, so much fury, I almost had to leave for fear of being unable to control my temper.

  I thought about the daughter, I thought about how she had tried so desperately to revive her father, and about how, no matter what else might happen to her in life, she would never be able to lose her memories of that day. I wondered how the man could have done it, knowing his daughter would be the one to find him, knowing how it would affect her. I thought about how these men were both the same age and had died on the same day, but how one had been given a choice about the matter and the other hadn’t.

  Many years later, and many patients later, I finally reached the truth.

  It took someone else to help me understand – someone I got to know on the psychiatric wards.

  He was a junior doctor.

  He was also a patient.

  Mirrors

  My first encounter with suicide was the death of a friend from medical school. Just a letter left to his parents with few words and no answers. No answers but many thoughts. I still knew very little if anything of the effects that the practice of medicine had on doctors. I, like many others, still ask myself if fear of the future was a trigger for his death, the secret thoughts that may have reflected his fears about a career where competition started to shape lives much more directly than a simple mark in an exam did in the past.

  The consultant

  When Alex was first admitted, he was fractured and confused.

  Looking back and reading through the history, as is often the case, you could see the red flags, snapping and fluttering in the breeze, but no one had spotted them at the time. Taking hours to clerk one patient. Sending long, rambling emails to his consultant in the middle of the night. Increasingly bizarre behaviour, it said in the notes when he presented himself to A&E, stating he felt unsafe. Self-harm and self-loathing. The wandering, lonely journey of someone who was trying to survive in a landscape that eventually he was unable to tolerate. By the time he reached us, he was showing signs of paranoia – suspicious of everyone around him and refusing to communicate. There were persecutory delusions, perhaps even auditory hallucinations – hearing voices – although we couldn’t be certain, because he wouldn’t engage with anyone. There were times, though, when he seemed to respond to sounds or to people that no one else could hear or see.

  He continued to believe he was working as a doctor for the ward on which he was now a patient. He was very convincing, of course. So much so, some of the other patients began to believe it too.

  Slowly, over the weeks, with support and talking, and medication and kindness, Alex began to improve. He started to trust us more. He felt comfortable talking about his thoughts and reactions, and he gaine
d back the insight into why he was there. We had long conversations, Alex and I. He talked about the stress he’d experienced as a junior doctor, how inadequate he felt and how much self-doubt filled his mind every day. I don’t think I have ever related more to a patient and their story. I’m not sure that I ever will again. This could have been me. I have always believed that the distance between a doctor and a patient is a short one, but never had it been shorter than with Alex. Most of all, though, we talked about his dog, Fletcher. In another strand that bound us together, he was completely and utterly devoted to his dog. A golden retriever with kind eyes and a goofy walk. He often took out his phone and showed me pictures and videos of Fletcher. While other patients would visit family and friends on a day’s leave, Alex would visit his dog in the boarding kennels. Through a tragic twist of fate and the impossibility of geography, he had no family and very few friends. Fletcher was everything to him.

  Alex was discharged on a Thursday afternoon in the middle of a heatwave. Before he left, we sat in the shade at one of the benches in the patients’ garden and talked for the last time. We talked about different jobs we’d had and the consultants we’d worked for, and we laughed at shared horror stories from the wards. He told me he would like to eventually go back into medicine, because he loved the job and he missed it. He talked about how much he was looking forward to picking Fletcher up from the kennels. It didn’t feel as though I was talking to a patient any more, it felt as though I was talking to a colleague.

  On the Saturday night, he hanged himself.

  I was told at ward round on Monday morning. I had known suicides before, but the shock was so intense, so unbearable, I couldn’t find any words at all for a few minutes. When I finally spoke, the first thing I said was: ‘No, there must have been a mistake, because he would never, ever, have left his dog.’

  Because I fell into a trap. I fell into a trap of believing that Alex had a choice, imagining that he sat at home on the Saturday evening and made a decision about whether he wanted to live or die that day, when in reality he had no more of a choice than someone who is killed by a heart attack or by bowel cancer. A disease ended his life, just like other diseases end the lives of people every day. I knew those thoughts were in my head somewhere, but it took me a few days to find them, to realise that choices are not black or white. Choices are coloured and shaded by our own thoughts and experiences, and our decisions are sometimes made – not only by us – but by the diseases that run through our minds.

  It was only then I looked back and remembered standing in a mortuary as a medical student, and being filled with rage and disappointment, and realised, finally, what I should have realised then – that, just like Alex, neither the man who had had the car accident nor the man who took his own life in a garden shed all those years ago had been given any kind of choice.

  In reality, what may seem like a choice can in fact be anything but, and it’s only when you visit a mental health ward that you begin to realise how small and how rationed those choices might be.

  Perhaps, in psychiatry, this is the most important role of all – to restore choice – because the restoration of choice brings with it the return of hope. Many patients arrive on the ward with a complete absence of hope, and a space in their lives where the idea of choice used to live. Choices are born from the acknowledgement of our own emotions, because how can we make a decision about something if we aren’t allowed to explore how we feel? The registrar in the mortuary allowed me to explore my feelings about death and by doing so, she handed me the choice of staying or leaving, and the hope that I might be capable of this job after all.

  In medicine, and outside of medicine, the need to preserve choice is vital, but perhaps it’s felt most keenly of all in psychiatry. A place where choice is so easily lost. A place where, in time, when that choice is found again, there is nothing more rewarding or more wonderful to witness than the restoration of a life worth living. Because the most important ingredient with which to mend a damaged life is hope, for the patient and for the doctor.

  Words

  Medical students practise suturing on oranges, they practise inserting cannulas into plastic arms and practise CPR on life-size dolls costing tens of thousands of pounds, but there is no way to practise talking to a patient. We bring in experienced actors, we set up imaginary scenarios, and we coach from the sidelines, but nothing can replicate the first time you are asked to deliver bad news. There is no script. There is no one providing encouragement and wisdom from the edges of the room. There is no second chance.

  The lecturer

  Exposure to the end of life, and acknowledgement of our feelings towards it, is one of the biggest challenges of being both a medical student and a junior doctor. Unfortunately, it is also the topic least spoken about, and dealing with death is a skill we are expected to acquire and improve on with experience, like taking blood or inserting a catheter.

  It was one of the first things I noticed when I finally reached the wards. How we pinball from one moment of crisis to the next without time to process our thoughts. How we are expected to move on to the next situation, the next tragedy, without speaking about the one we have just left behind. How we are expected to carry these parcels of grief around with us each day or learn very quickly how to build walls to shield us from the suffering. But in caring for someone you instinctively begin to care about them, and when something happens to the people you care about, there is no wall strong enough or thick enough to keep you out of harm’s way.

  For the first eighteen months of medical school, we spent most of our time in a lecture theatre, locked together in the darkness, absorbing anatomy and pharmacology and physiology. Trying to understand the process of disease. Drawing carefully shaded diagrams of the inguinal triangle. Halfway through the second year, however, for one afternoon a week, we were permitted to make the excitable fifteen-minute walk to Leicester Royal Infirmary, where a tired and over-worked consultant valiantly tried to prepare us for life on the wards. We took that fifteen-minute walk many times over the next few years, but we were never quite as enthusiastic as we were on that first journey, our stethoscopes swinging around our necks, a spring in our step. It felt like we were being given a small reward in return for all the hours we had spent buried in our textbooks. For the first time, we felt like real doctors, and we said this to each other over and over again as we walked.

  The consultant we were assigned to on these precious days in the hospital was a paediatric radiologist. He was wise and experienced. He knew just how to oxygenate our excitement without letting the fire get out of hand. We gathered in a small room off one of the wards and he allowed us to taste dilemmas and scenarios, case studies and food for thought. We could hear patients in the background. Real patients, only a few feet away. We were giddy with excitement.

  ‘Imagine,’ he said to us one day, ‘that you are seeing a patient about an unrelated condition, and he mentions to you that he has a pre-existing diagnosis of lung cancer. What would you say to him?’

  Our nervous little group of eight all side-eyed each other. I was the oldest. I was supposed to make a fool of myself first.

  ‘I’d tell him I was very sorry to hear that,’ I said.

  The consultant frowned into my very soul. ‘No. No, you would not. In fact, that’s the very last thing you would say to him.’

  I made a small attempt at arguing. As a second-year medical student, I didn’t have very much, but I did have buckets full of compassion to throw around to make up for an absence of actual knowledge. Doctors were supposed to be kind, weren’t they? Empathetic? What on earth could I say, if I couldn’t say I was sorry?

  ‘You would say thank you for telling me that information,’ the consultant said. ‘Saying you’re sorry is a value statement. Those are heavy words, and you might be giving him a weight he is unable to carry.’

  He was right. Of course, I know now, he was right. Back then, though, I couldn’t understand why saying you’re sorry about someth
ing was such a problem. Now I understand. Now I understand that each word we give to someone else carries its own burden, and one person’s light-as-air is another person’s unbearable cargo. We each measure words with different scales.

  I learned a lot about the measuring of words as I travelled through medicine. As a (very) junior doctor, I once had the difficult task of telling a young man (and his family) that he had a diagnosis of schizophrenia. It was a diagnosis made by someone much wiser and more experienced than I was, but thanks to a combination of flooded roads and a prearranged, urgent meeting, I was the one bearing the news. I did the best I could. I remember that they were all, understandably, very upset, and I remember saying to this young man that he was exactly the same person as he had been five minutes ago. Nothing had changed, I had just given him a word. He was still the person he was before. But of course, he also wasn’t. Because with that one word, I had given him more weight than anyone should ever have to carry in a lifetime. Because words are never, ever, just words.

  A few years after my conversation about the dangers of saying you’re sorry, I was sent to a county hospital on a final-year medical school rotation called Cancer Care. It was a five-hour round trip, which always gave me plenty of time each day to reflect on ‘cancer care’ and how the meaning of those words isn’t quite as obvious as you might think.

  As a student, one of the challenges of being at that hospital – at any hospital – was Finding A Patient To Talk To. It’s what medical students do for most of their time. They circle the wards desperately looking for a patient who is willing to tell them a story. It’s a way to practise history taking, to understand investigations and medications, and treatment plans. When you arrive on the wards, role play becomes reality, and the page in a textbook becomes someone’s life. Talking to patients is the very best way to learn, but it isn’t always easy.