Breaking and Mending Read online

  The consultant

  Medical school was over.

  Exams were taken, dissertations were handed in, practical stations were tested. For the past few months we had all lived in a knot of anxiety. Waking in the night to check something in a textbook, breaking under the weight of so much knowledge, yet secretly believing we knew absolutely nothing. Blistering in the heat of so much pressure, not only our internal pressure but the unintentional external pressure from those around us.

  Each time I sat an exam, I would ring my mother as soon as I came out.

  ‘How did it go?’ she would ask.

  ‘It was awful. Everyone said how awful it was.’

  ‘Yes, but … you do think you’ve passed … don’t you?’

  If I had failed and I was the only one who needed to come to terms with it, it wouldn’t have been a problem, but – like everyone else at medical school – it was the spectators I was worried about. All the people who had stood at the side of the pitch for five years, cheering us on. The parents and husbands and wives and friends. All the sacrifices and the understanding, the support and the kindness. We wouldn’t have failed just an exam, we would also have failed the people we cared about most in the world.

  That pressure split apart the fracture lines that had already begun to appear. We tried to hold each other up through the revision and the self-doubt. Looking out for those around us. Trying to spot when someone was falling. We weren’t always successful.

  If you had asked us on that first day of medical school, if you had questioned us about the journey ahead, we would have told you it was going to be the longest one of our careers. Five years sounded like a lifetime, but it was finished in the blink of an eye. I walked to my car after the final exam, back to the place where I had parked every day for the past five years, and I sat for a while in the silence. I had, hopefully, reached the finishing line – although I wouldn’t know if I had passed my exams for a few weeks – which meant I might be driving home as a student for the very last time. It felt like there should be balloons and banners all the way down the A50. Instead, of course, the world continued with its day all around me and I went home to wait for the outcome.

  I didn’t go to the medical school on results day. Instead, I opted to stay at home and receive an email. Most people went in, however, and slowly a trickle of posts began appearing on social media. Champagne and hugging. Tears. Smiles. Joy. Relief. Finally, my email came through. I hunted down my mother.

  ‘I’m a doctor!’ I said. ‘I’m a doctor!’

  As though it were that simple and, in the space between one second and the next, we all became someone new. There is no other degree that changes your identity, that somehow manages to alter your perception of who you are. There is no other degree that carries with it such a glorious history and that ushers you into its celebrated, but occasionally notorious, fraternity. Alexander Fleming, Joseph Lister, Elizabeth Garrett Anderson, Christiaan Barnard. Conan Doyle and Keats.

  There were doctors whose impact was so great that we borrowed their names and gave them to the conditions we had just learned about. Hans Asperger. Burrill Bernard Crohn. George Huntingdon. Alois Alzheimer. We looked at ourselves in the mirror, brand new and shiny, barely harvested junior doctors, and we wondered if we would make even a tiny fraction of that impact.

  The next time I went to the medical school, it was for graduation day.

  I had been chosen to read the Declaration of Geneva. I have no idea why they picked me. I certainly wasn’t representative of my cohort, because, as well as my age, each evening for the past five years I had got into my car and I had driven away from a large part of medical student life. I didn’t live in halls. I’d never set foot in the Student Union. I belonged to no societies or clubs and, although I had enjoyed the time I did spend with other students, our lives weren’t knitted together in the same way they might have been.

  Reading the Declaration still remains one of the proudest moments of my life. I stood in a hall filled with hundreds of students and families, teachers and lecturers, and I led the doctors’ oath, a version of which had been repeated hundreds of times over the decades. We recited the words, but we couldn’t understand the true impact of their meaning or the many different interpretations which could be drawn around them.

  I solemnly pledge to consecrate my life to the service of humanity

  I will practise my profession with conscience and dignity

  I will maintain the utmost respect for human life.

  It was a grand auditorium, with red velvet seats and a pipe organ. Giant beams stretched above our heads. Gowns and mortar boards scattered over the seats and spilled out into the hallways. Parents cried. Everyone clapped. As each name was read out, there were cheers and shouts. We repeated our oath and made our pledges with the utmost sincerity. Each sentence was meant, each vow considered, but words are always defined by their landscape, and words said in a grand auditorium with red velvet seats are very different to words remembered in the rush of a crash call or at the bedside of a dying patient. We thought we knew what those words meant, but their meaning would evolve with every step we took as doctors. There would be times ahead when we would need to turn away from our consciences. Over the years, the meaning of dignity and respect would be examined and we would take their definitions and turn them over in our minds. In our darkest hours, we would even begin to question the existence of humanity itself.

  Since our graduation, the Declaration of Geneva has also altered and evolved. It now contains the vow: I will attend to my own health, well-being, and abilities in order to provide care of the highest standard.

  Perhaps of all the vows and promises this is the most difficult one to keep.

  For all their training, for all their knowledge and expertise in sustaining good health, attending to their own well-being is something that doctors are not especially good at. The focus is always on the patient, solving the puzzle of the person in front of us, not resting until we find our answer. Sacrifice and the surrender of the self are woven into the job, and going without food and water and sleep are also vows every junior doctor seems to be expected to uphold. Look after yourself, we are told and then we are placed in a situation where self-care is impossible, and even seen by some as unpleasantly self-indulgent. Protected mealtimes say the leaflets we are given, as the bleeps and the phone calls and the requests never stop. Get home safely they advise us, as more than half of junior doctors report accidents or near misses when driving or cycling home from a night shift, purely due to sleep deprivation. In a 2017 survey, a third of doctors reported having no rest facilities at the hospital where they worked, and in one of my jobs, all the beds were removed from on-call rooms in order to prevent doctors from taking a break.

  I started hallucinating on the motorway, one junior doctor told me.

  I stopped at a set of traffic lights and the next thing I knew, a driver had pulled alongside me and the sound of his horn woke me up, said another.

  Since 2013, at least three trainee doctors have died in car accidents following night shifts. At the inquest into one death, it was reported that the doctor was singing on the drive home, to try to keep himself awake.

  A few years after graduation, I found myself working in A&E as a junior doctor. I had been there for twelve hours without eating or drinking – something that wasn’t unusual and was certainly not considered an issue by anyone in the department. However that day, perhaps through the accumulation of many days filled with twelve-hour shifts, I began to feel faint. Waves of nausea tumbled through me and a rushing sound began to fill my ears. My hands were shaking too much to even write in the notes and I certainly didn’t trust myself to take blood from someone or insert a cannula. It was affecting my judgement, my reaction time. Extreme tiredness and lack of food have the same effect as being drunk and I was worried that I would make a mistake.

  I finished dealing with my patient and I looked around for a chance to escape, just for a minute. The departm
ent was in chaos. Every bay was filled, every bed occupied, and a line of paramedics and their patients snaked down the corridor, through the double doors and into the car park. The sense of guilt and shame was overwhelming, but the sense of imminent collapse overwhelmed me just a fraction more. I could be back within three minutes so I had just managed to talk myself into making a run for it when my consultant appeared and told me which patient I needed to clerk next. It was late at night and I knew the canteen would be closed in ten minutes. I didn’t want a three-course meal; I didn’t even want a sandwich. A bar of chocolate. A biscuit. Something I could eat while I worked. Something to bring me back to being able to function safely. Something to make me useful again.

  ‘I really need to eat something,’ I said in a very small voice.

  He stared at me. ‘There are patients waiting.’

  ‘It’s the patients I’m thinking of,’ I said.

  The look of disgust on his face was so clear and so obvious I can conjure it up at a moment’s notice even now, years later. I never asked for food again.

  Medicine is a vocation, not a job, we are often told. The reality is, it is both, but when the conditions of the job become unbearable, when the demands made of us are likely to put our own lives at risk, not to mention the lives of the patients in our care, we are expected to continue to bear it because of a deep-rooted sense of purpose. A calling to serve and heal, and to fix. Or perhaps we are drawn to fixing others, because, by doing so, we might inadvertently succeed in fixing ourselves.

  Graduation felt like the end. It felt as though we had arrived at our destination and the journey had reached its conclusion. Little did we know that the past five years had just been a prologue, a short introduction to what lay ahead. In our minds, we had passed the finishing line, but in reality we had only been walking, very slowly, towards the start of the race.

  In a beautifully circular pattern, the same professor who had delivered our opening lecture at medical school and who had welcomed us to the first day of our medical career, also delivered to us the final words we would hear as students.

  He stood on the stage in the grand auditorium, he leaned on the podium, and it felt as if he managed to look each one of us straight in the eyes.

  ‘Now,’ he said, ‘the hard work really begins.’

  Once again, he was right.

  Harvested

  There is a running joke that you should avoid being admitted to hospital at the beginning of August, because that’s when all the new doctors arrive on the wards. In truth, it’s the very best time to be admitted, because what new doctors lack in experience they make up for in enthusiasm and compassion. They are yet to be worn down by frustration and tarnished by a broken system. They answer their bleeps immediately, they have time for everyone. They care. There are a few who think nurses are beneath them, but we have ways of putting them right on that score.

  The nurse

  On a bright, sunny morning in August, the machinery of the NHS turns and all the junior doctors change jobs.

  Amid that change, a new harvest arrives, filled with enthusiasm. They are processed, inducted, initiated. They collect bleeps and lanyards, swipe cards and pagers, and they disappear into the wards and along the corridors, where they are swallowed up into the hospital.

  I had spent the previous two weeks ‘shadowing’ my predecessor, a young woman grey with exhaustion and worn down at the edges, who tried to pass on a stream of insider tips for survival, as a parent would to a child.

  ‘The vending machines upstairs never work,’ she said.

  ‘Don’t rely on the cashpoint near the porters’ lodge, because it’s always broken.’

  ‘The nurses on Ward 4 are the nicest. They’ll make you a cup of tea.’

  She told me which consultants were religiously early, and which consultants started a ward round ten minutes before you were due to end your shift. Which consultants you could go to with a problem, and which were best avoided.

  ‘Don’t go near her when she’s wearing black,’ was all she said about one.

  She showed me the telephone system and the layout of the wards, how to order an X-ray and how to check blood results on the computer. Extension numbers, requests for porters, paperwork and pharmacy. What to do if you get a needle stick injury. Where the death certificate book is kept. The best parking places. The quickest route from the mortuary to the doctors’ mess. I wrote some of the things down and the rest I tried to commit to memory. Like a Labrador puppy, I trotted behind her all day and watched from the safe shelter of the periphery.

  On my first day, of course, she had gone.

  My job was in urology. A magical mixture of bladders, testes and ureters. There was everything from kidney stones to testicular cancer, enlarged prostates to difficult catheters, and, alongside them, an endless supply of elderly patients who – for a wide variety of usually mysterious and unexplained reasons – had stopped being able to pee.

  Surgery days always begin earlier than medical days, and at seven-thirty I arrived for my first shift as a doctor, allowing myself an extra half an hour to find a free computer and print off my patient list, which would eventually turn out to be the first challenge of any morning. The ward round began at eight sharp and this gave me just a couple of minutes to spare in which to congratulate myself for finding the right ward, and for making it on time and with all the various bits and pieces I needed to have about my person.

  Surgical ward rounds are fast. Unlike medical ward rounds, which often pause for reflection and conversation, and sometimes last all day, surgical ward rounds are swift, clean and unfussy. Surgeons belong in theatre, and I often wondered if some of them saw speaking to patients as more of a sideline. A minor distraction before the real work began. The consultant coasted through the ward, occasionally stretching out a hand for a set of notes or an observations chart. We scrambled behind him, trying to keep up, arguing with unruly cubicle curtains – which were no sooner drawn to than he was on his way again – and the notes trolley became a vehicle of chaos. We each had a job on the ward round, and mine was to prescribe the medication, which was all done electronically. I could barely remember my log-in details, let alone my PIN number, and I couldn’t hear what the consultant was saying above the noise of the trolleys and the breakfast plates. I didn’t dare ask him to repeat it. The laptop teetered on the edge of a tower of notes. People moved it to retrieve those notes and it shut itself down. I managed to restart it and log myself in, but it was borrowed and taken away, and someone else logged me out. I tried and failed to put my details in again. The laptop became very angry and locked me out of the system altogether. I began to shake. The senior house officer (SHO) leaned over and pressed a few keys. He typed in all the prescriptions that were needed in a matter of seconds, and when he finished, he looked at me.

  ‘Don’t worry,’ he said. ‘It gets better.’

  At the end of the ward round, the consultant disappeared to theatre and the rest of us were left in the wake of a tornado, with a jobs list to divide up between us. There were notes to write, discharge letters to type, medications to change and blood tests to chase. Everything in medicine is chased. Chase that, a consultant will say, tapping at an X-ray report or a bloods request, and you will find that your to-do list is mainly comprised of things you are required to run after. It was a list that stretched across the day and late into the afternoon.

  My predecessor was right, though. On Ward 4, the nurses do always make you a cup of tea.

  By the end of the first week, the SHO’s prediction came to pass. It did get better. I learned my log-in details by heart. I knew to be prepared, and to prescribe ‘as needed’ pain relief and anti-sickness for anyone returning from surgery. I knew to clip consent forms to the front of notes and to make sure no patient was ever sent to theatre without a cannula in place. I began to feel more relaxed. Bedded in slightly. Perhaps even a little bit useful.

  Unfortunately, though, medicine never allows you to relax for very lo
ng, because no sooner had I completed a week of day shifts than the timetable changed again. I was about to roam the corridors alone for hours at a time, not only called upon for my own patients, but for any surgical patient in the hospital.

  I was about to start my first set of nights.

  The hospital at night is a different country. The first thing you notice is the absence of sound. In the day, there is a white noise of trolley wheels and telephones, conversations and footsteps, and on every corridor great waves of people move towards you – nurses, doctors, porters, cleaners. The crash and clatter of laundry carts and meal trays. The reassurance of sound. During the day, there is no corner of the building where you are able to find even a small space of silence.

  At night, everything is made out of silence. Not until noise is removed do you appreciate how comforting it is to hear the distant work of other people. Apart from a trickle of evening visitors, heading back towards the car park, I saw no one on my walk to handover. The shutters were down on the little shops and at the florist’s, and upturned chairs rested on the coffee-shop tables. A row of secretaries’ offices, usually an engine of efficiency, all stood in darkness. Computers sleeping. Mugs rinsed on draining boards. Tea towels folded. I passed A&E, a place where the terms day and night cease to have any meaning, and the bright lights and sound of people talking provided a small consolation. I was not alone. There were other doctors scattered around the hospital, and among them, somewhere, was my registrar. The person I turned to if I needed help or if I felt out of my depth. All I had to do was call his bleep and he would be there.

  Evening handover was held in a small teaching room on the top floor. I was the first to arrive and I waited in the hum of a strip light, alongside a broken projector screen and a plastic skeleton. To pass the time, I stared at the list of symptoms written on the whiteboard and tried to work out what had last been taught, but the notes made no sense to me. My inability to recognise them sent me into a small panic. What was I even doing there? I knew nothing. I was a fraud. A charlatan. It felt as though, at any moment, a GMC police officer might march through the door and arrest me on the spot for being an interloper. I took a small collection of talismans out of my pocket for reassurance. My stethoscope, a notebook and pen, a laminated card of out of hours bleeps – pathology, radiology, ECGs and the ever-present portering services – and a long list of extension numbers for every ward in the hospital. I took out my tourniquet, which had cartoon bats printed on it and was clearly designed for paediatrics. When I’d bought it, it had seemed amusing, but in the stark light of that teaching room it felt almost grotesque. Lastly, I had a reference book, a handy guide for junior doctors that we all carried around with us: bullet-point lists of what to do and what to check and what to prescribe in different situations, as if all of life’s emergencies could be condensed into a small handbook and stored neatly in your pocket.