Breaking and Mending Read online

  They didn’t. Although, they said, they probably wouldn’t be in hospital for very long.

  I pulled up a chair. ‘It’ll only take ten minutes,’ I said.

  I was there all afternoon.

  We went through the presenting complaint, the signs and the symptoms, relieving factors and aggravating factors, and medications and family health, and all the other side roads you wander along when taking a patient history. As you become more experienced, there will be some roads that you may only need to glance down, knowing exactly the route you need to take, but as a student, you very carefully walk the length of each one, worried about missing something important, determined to ask all the questions until you find the answer you’re searching for. I wrote everything down. I made a note of the tests that had been ordered and all the observations that bleeped away at the side of the bed. Two little girls played at my feet.

  ‘I couldn’t get a sitter at such short notice,’ said Paul’s wife.

  She told me their names and their ages. They were becoming bored, fractious. I went to one of the children’s examination rooms to get them a fresh supply of toys. When I returned, they told me about a holiday they had planned for the following week. They owned a caravan in Cromer. Paul was a taxi driver, so he could take time off when it suited them. My dad used to drive taxis. We talked and talked. I think it was a distraction for them, and creating a source of distraction meant that it was one of those very rare times I felt useful as a medical student. But it meant that I didn’t spot it. I didn’t see what I had done.

  There is another space in medicine.

  A space that exists between a patient and a medic, and I had walked straight across it without realising.

  It’s a space that exists for a reason.

  Paul was admitted for more tests, and so he and his wife, and their two little children and the toys and coats and carrier bags were all taken from A&E and wheeled through the hospital to one of the wards. I followed them down the long corridors. I saw the surprise on their faces. I witnessed, on the first of many, many occasions, how the very worst day of your life often starts out very cleverly disguised to appear just like any other.

  I thought about them on the drive home. I thought about them while I was eating my supper, walking my dog. I lay in bed in the darkness, staring at the ceiling and thinking about them. As a medical student, I possessed very little medical knowledge, but I switched the light on, pulled one of my textbooks from the shelf, and looked at causes of jaundice, and I picked out the ones that suited best the darkness and the thinking. I had begun to consider them as friends, and, as I swam around in the space that lies between the doctor and the patient, I tried to find something I could hold on to.

  Every day, I visited them. After the lectures and the ward rounds, after I’d filled in my workbook for the morning and ticked all the boxes I needed to tick, I’d head to the far side of the hospital and check what was happening. I was supposed to, of course, because this was my case study and I needed to keep up to speed, but I knew it was more than that. Even as I walked the long corridors towards the ward and swiped myself through the door with my student pass. Even as I took my workbook out and pulled a pen from my pocket. I knew I was no longer there because I needed a case to present at the end of my rotation. I was there because I cared.

  I had heard the conversations at the nurses’ station. I had sat in a medical student silence through the ward rounds. I had seen the scans. They had found a mass. There are many small, significant words in medicine, but mass has to be one of the more sinister. A gathering of cells. Interlopers, serving no purpose, tunnelling their way through the body in secret, as we eat and sleep and enjoy our lives, strangely unaware of their existence, until one day, they wrap or cloak or fold themselves around a part of us that we need, and finally we become conscious of their presence.

  Usually, on a scan or an X-ray, these abnormalities have to be pointed out to students, because we are as yet unable to differentiate between what should and shouldn’t be present. All the organs look vague and puzzling, and we struggle to relate the images we see on a screen to the textbook life we have been used to. But this scan was obvious. This scan was barn door, as the radiologists are fond of saying. The mass had buried itself deep within the pancreas, squeezing and pressing, determined to flourish, and elbowing into anything that might lie in its path, including the bile duct, which had, in turn, led to the jaundice. More tests were required to determine the nature of this mass and what its intentions might be, but everyone seemed pretty sure, even without them.

  This was pancreatic cancer.

  ‘But he’s thirty-eight,’ I said to the consultant.

  ‘This is life,’ he said. ‘This is medicine.’

  ‘It could be something else though?’

  ‘Painless jaundice is cancer of the pancreas until proven otherwise.’

  It was in medical textbooks. I had written it down myself in lectures and workshops, but this didn’t feel like a medical textbook any more. It felt like a person.

  ‘But you’re not 100 per cent certain?’ I said.

  ‘We’re 90 per cent certain.’

  I took my 10 per cent from him and held on to it very tightly.

  More tests were done. Paul’s wife brought in a paperback she thought I’d like and, to give them both a break, I often looked after the children in the day room. Sometimes, I fetched Paul a newspaper from the hospital shop, sometimes, I chatted to his wife about last night’s television, and, slowly but surely, I inched my way across that space. No one stopped me. No one turned me around and warned me, because no one teaches you about this space in medical school. Perhaps it is assumed that we will recognise it for ourselves, perhaps we are supposed to identify its dangers without any guidance, but while doctors are meant to lean back, far away from the abyss, it is a basic human reflex to reach across – to discover a connection, a common ground, to find something of yourself in other people. I reached across because it felt like the most natural thing to do.

  I had no idea it would eventually be my downfall.

  There was a multi-disciplinary team meeting. An assembly of specialists. Doctors and nurses, hospital staff and community workers, all gathered in the darkness and staring at the black and white pictures of strangers. Images of livers and bowels, gall bladders and stomachs projected on to a giant screen. No patients were present. Hope and possibility were passed back and forth across the room. Predictions forecasted. Statistics quoted. Risk assessed. Battle lines drawn and defeats accepted.

  Paul was on the list that day, and I sat in the corner of the room in a hard-back chair, waiting in the dim light with a cotton-wool throat for our turn. Because it was an our turn now. It felt like it had been all along.

  Finally, my consultant spoke. He pointed to the screen and a little red dot travelled around the pictures. He explained the landmarks, for my benefit, and – like many names in human anatomy – they sounded like far-flung destinations on a magical journey. The superior vena cava, the common bile duct, the triangle of Calot. The tumour’s position had made surgery an impossibility, and, as if that weren’t enough, the cancer appeared to have spread – there was a scattering of spots on the liver, shadows on the lungs: an army of cancer cells, silently marching their way through Paul’s body. They talked about stents and the possibility of chemotherapy, they said the word palliative. They talked about weeks not months.

  I gripped the sides of the chair. There must be something they could do, all of these experts – all of this intelligence, all of this resourcefulness crowded into a curtained room – and yet no one could suggest anything more. The image on the screen changed to someone else and they moved to the next person on the list.

  My consultant sat down and Paul’s moment was over. He was thirty-eight. He’d never smoked, he hardly drank. He ran the London Marathon four years ago. He had two little girls and a caravan in Cromer. He liked Monty Python and he played football every Saturday morning with his f
riends. His wife was called Julie and they met on a dance floor in Birmingham quite by accident, in the summer of 1996, when beer was one pound and seventy pence a pint.

  I held all these thoughts in my head because I knew these were the things patients say when they’re told a diagnosis: offering them piece by piece to the teller, as if evidence of the unfairness and the unlikeliness of it all will make the diagnosis realise its mistake, change its mind and walk away. These were not my words to speak, this was not my battle to fight, and so I left. I couldn’t go back to the ward because of a strange sense of fraudulence, and so I wandered the hospital for the rest of the day. I sat in corridors and coffee shops. I listened to fragments of conversation, walked past the splinters of other people’s lives.

  A hospital is like a small town. It has shops and a bank, restaurants and a florist. It has a resident community and a wandering population of those who just journey through, and, right at that moment, I couldn’t decide which one I wanted to be. I just knew I had to keep walking, trying to find my way across that great abyss, back to being a doctor. It was only when I’d finished walking, along corridors I had never walked before, past doors and departments I had never seen, that I finally arrived at the truth. Once you have crossed that space between doctor and patient, no matter how hard you might try, you will never be able to navigate your way back home again.

  My consultant asked if I wanted to be there when he told them. I said no. There is nothing more distasteful, nothing more selfish, than the appropriation of someone else’s grief, and I was worried that once I was in the room, I wouldn’t be able to hide my own selfishness.

  I watched from the nurses’ station as Paul and Julie were shown into a side room, a tiny space off the main corridor to the ward. I had been into that room before. It contained four easy chairs and a coffee table, and it was so small it took a huge amount of concentration just to avoid brushing your knees with your neighbour’s or accidentally digging into someone else’s ribs with your elbows. I wondered how a room that size was going to be able to hold the huge amount of agony it was about to receive. A Macmillan nurse was the last to go in and my consultant looked straight into my eyes as he closed the door behind them all.

  They seemed to be in there forever. I wandered around the ward. I talked to other patients I’d got to know. I ticked a few boxes in my workbook. I decided it was better to disappear into another part of the building and stay completely out of the way, and as I walked back down the corridor towards the main entrance, I glanced at the closed door of the side room.

  There are some rooms in a hospital that are designed for delivering bad news or made especially for people to sit in while they wait to receive it. The rooms near Resus in A&E. A corridor of small rooms in ITU. A soft, quiet room on the maternity ward, away from the balloons and the cribs and the congratulations banners. These rooms are used for other things as well, of course. They can be used for explaining and planning. Occasionally, you will catch a junior doctor in one of these rooms, eating their lunch and practising a presentation. Sometimes, they are used for giving good news to a patient, but good news is usually delivered at the bedside. Good news is allowed to wander around freely and stretch its legs. It’s allowed to travel through cubicle curtains and make its way around the ward and be heard by anyone who might happen to walk by. It’s bad news that needs to be contained. Trapped. Kept tightly enclosed in a small room with four easy chairs and a coffee table, just in case it should manage to escape and be heard forever.

  I returned to the ward half an hour later. The door to the side room was still tightly closed.

  ‘They haven’t come out yet,’ said a passing nurse, because she knew me well.

  Half an hour later, Paul and Julie emerged from the room. They were different people, because misery always breaks you, and even though you will eventually manage to fit the pieces back together, you will never look quite the same again. They moved slowly back across the ward, Paul and Julie, the Macmillan nurse and the ward sister, and the curtains were drawn around the bed. My consultant sat at the computer next to me and typed something into the keyboard. He didn’t make eye contact. When he’d finished, he stood up and said ‘what a lovely family’ and he left. I wondered, even with wisdom and experience, even with the many miles of hospital corridors he must have walked, if he sometimes couldn’t help but take a few steps across that space himself from time to time.

  I didn’t speak to Paul or Julie until the next day.

  ‘Did you know?’ Julie said.

  I shook my head. ‘Not the last time I saw you. Not until just before you were told.’

  ‘It doesn’t make any sense.’

  She spoke the words as a question and searched for an answer in my face. I would see that search many times when I became a doctor, the natural assumption that someone with knowledge must also possess a solution, an explanation. The forgivable belief that, as well as understanding the anatomy and the physiology, we are also given the key with which to unwind something and make a life turn back into what it used to be.

  ‘He was as fit as a fiddle,’ she said. ‘He ran the marathon. He played football.’

  ‘I know,’ I said. ‘I know, I know.’

  We looked at each other in a shared disbelief and I felt this huge need to apologise. For myself and for my ignorance. For medicine’s inability to save her husband. For my own selfish misery, which I am certain spilled into my eyes.

  Paul watched us from the bed. He looked more jaundiced, thinner. Less likely to survive, although perhaps it was the absence of hope that I was seeing for the first time.

  ‘We’ll have no long faces here,’ he said, and I watched him put all his effort into making us both feel better, smoothing down an easy road to walk along, taking each obstacle and carefully placing it to one side.

  Terminally ill patients do this frequently. I sometimes think they use more energy helping everyone else to deal with the situation than they do in coming to terms with it themselves.

  They tried stenting, to find a way around the blockage, but it failed. They tried chemotherapy, but he couldn’t tolerate it, and I was just finishing my placement when the palliative care team organised a bed at the hospice.

  I had already met patients who had stayed with me, people who remained in my thoughts long after they had left, but until that moment I had managed to continue walking forwards. I somehow always pulled myself away from a dark corner of thinking and directed my energy into the next patient, the next cubicle. This time, though, the stent failed. I couldn’t find a way around it. This time, I couldn’t move on. I knew where I’d gone wrong, I knew I’d walked a path I shouldn’t have walked, but equally, I knew I would walk it again. Again and again. When I wrote a card for what would be an elderly couple’s last anniversary. When I ran around the hospital hunting down ice, for a dying woman in A&E who craved cold water. When I smuggled fish and chips on to the ward, for an old man who had lost his wife and couldn’t face eating. None of these make me special or unusual, thousands of medics and nurses do things like this every day. It’s what makes us human and, sometimes, walking across that space towards a patient is the only thing we are able to do for them.

  I watched them leave the ward, Paul and Julie, and their two little children and the toys and the coats and the carrier bags. An ordinary life suddenly made unordinary by a cruel disease so quiet and so devious we are often unaware of its existence until it’s too late. I knew that all the words you normally attach to a goodbye were worthless, and anything else I said would be for my own comfort and not for theirs, and so we just smiled at each other.

  I was planning on telephoning the hospice a couple of weeks later. I even got as far as writing down the number and keeping it in my pocket, but I didn’t ever get around to calling. On my next placement, I was walking in a different part of the hospital, towards a different ward, when I spotted their Macmillan nurse, on the opposite side of the corridor. I thought of asking her how it went, I thought
of finding out the end of the story, even though I knew what the end of the story would be. She recognised me and she smiled. I didn’t ask.

  I didn’t ask her because sometimes we need to leave a space. A space between a doctor and a patient. Between one person’s story and our own.

  A space where we can put all the hope.

  Beginnings

  I have a box full of paracetamol in my bedside drawer. I am so scared of letting my parents down, I worry I might not be able to stop myself from taking them all.

  The medical student

  I have driven home many times after a night shift without feeling safe to do so. The rota doesn’t allow enough time between working days and working nights for your body clock to adjust, and so you feel permanently tired. It affects my judgement – not only when driving, but when dealing with patients. Occasionally, I have slept for half an hour in the staff car park before setting off, because I’m worried I will kill myself or, worse still, kill someone else. Everyone is the same, but you can’t speak out because you would be seen as a troublemaker.

  The junior doctor

  My experience after medical school was marked by compulsory military service and of meeting many others of very different backgrounds who saw me not just as me but as the doctor. For the majority, a figure of comfort, but for some a figure with power that needed to be controlled or used if not abused in order to get something – control or special privileges. The period that taught me that conflict was part of being a doctor.