Breaking and Mending Read online

  The outgoing doctor arrived to give me the on-call bleep. He apologised for the long list of jobs he was about to read out, because there is an unspoken rule in medicine that you don’t hand over jobs in handover – a rule which is impossible to follow. His scrubs were creased and tired, and he looked as though he hadn’t slept for a week. The bleep sat between us. It went off six times while he was talking, because, as I would very soon learn, the silence of the hospital at night is just a smokescreen, and buried somewhere in that silence there is the never-ending sound of small tragedies.

  The only other person present in handover was the site nurse practitioner, one of the most experienced nurses in the hospital, who patrolled the wards during the night assessing the most unwell patients, alerting the staff to any problems, sorting out beds and difficult cannulas, ensuring the hospital ran smoothly, and tidying up after the doctors. I didn’t know it then but she would be my guardian angel, her name was Claire and the fact that she was Irish just added to the sense of relief. I would have quite liked Claire to follow me around for the rest of my life, giving me a gentle push to believe in myself and a hug of reassurance when I needed it.

  After they left, I sat alone studying the list of jobs I had been given. The bleep went off three more times. I rang all the numbers and added more jobs to my list.

  A lot of medicine is learning how to prioritise, to decide which patient needs to be seen first, purely from a quick phone call. Is it the man on Ward 4 whose blood pressure has dropped? Is it the woman on Ward 7 with a temperature? Is it the patient who has just arrived in A&E with a short history of vomiting and abdominal pain? I learned as I walked the corridors, and I slowly began to develop an instinct, a sixth sense that told me which patient I needed to see first. Sometimes, I was wrong, but the more times I got it right, the more my confidence began to grow.

  I didn’t hear from my registrar. I caught a glimpse of him occasionally, when I passed through A&E, but our paths never crossed. As well as developing an instinct about the patients who needed me most, I also learned that there are different kinds of registrars – those who enjoy bleeping you every hour to find out exactly what you’re up to, and those who like to walk the corridors alone.

  As the night continued, staying awake began to be an issue. While adrenaline had kept me going for the first few hours, a broken, anxious sleep the day before meant that by 3 a.m. I had started to flag. I foraged from vending machines. Rich chocolate and paper-cup coffees. Crisps and little pots of cream cheese. Even in the brief moments when I hadn’t any jobs to do, I walked the corridors to stop myself from falling asleep, and, in an act of desperation, I stepped outside the doors of A&E and took in a huge lungful of cool night air to wake myself up. There were no on-call rooms, no beds put aside for night doctors, and all over the hospital, bodies of sleeping medics littered waiting-room sofas and office floors, as they tried to catch a twenty minute nap, their bleeps pressed into their faces. I didn’t dare. What if I couldn’t wake up? What if I slept through until morning and was discovered by a cleaner stretched out on the carpet? What if someone died?

  The night walked on. I reinserted cannulas in darkened bays. I prescribed sleeping tablets, reviewed patients, took bloods ready for the eyes of the morning teams. I ordered ECGs and put catheters in. I walked cultures down to pathology. Somewhere along those corridors, somewhere between the hours of midnight and six in the morning, I began to feel useful. I felt as if I had a purpose. For the first time, it seemed as though all that training had grown into something worthwhile and I began to feel like a doctor.

  There is a point on a night shift when one day turns into the next. It seems to rest on only a fraction of time. The first laundry truck appears. You catch a glimpse of a cleaner along one of the long corridors. The sounds and smells of breakfast drift along the walkway leading to the canteen. It’s not just the people and the increase in activity, though, it’s more to do with a change in the air, a sense that the building is stirring and waking to a new day. As the giant clock in A&E clicks from one second and into the next, there is a brief moment of limbo – a grey space of nothing – and then morning appears to take over the reins.

  I had survived my first night shift. Despite the tiredness, I was elated.

  My second night shift went just as smoothly. There were a few admissions, a few unwell patients on the wards who needed reviewing and monitoring, but, other than that, I continued with my on-call staples of cannulas and bloods, sleeping pills and pain relief.

  I met my registrar, quite accidentally, in the corridor leading to the orthopaedic ward.

  ‘Everything okay?’ he asked.

  ‘Everything’s okay,’ I answered.

  It was the only time I spoke to him all night.

  By the third shift, I had shaken off almost all of my anxiety. I parked my car and practically marched towards the hospital entrance. I was smiling, at ease. I was almost looking forward to it.

  I didn’t realise I was about to experience the very worst night of my life.

  The Darkest Hour

  I have seen junior doctors bullied by consultants. I have seem them intimidated and persecuted, humiliated on ward rounds in front of patients and nurses, deliberately made to look stupid. Some consultants give nothing but kindness and support, while others seem to go out of their way to make their junior’s life a misery. Student nurses are more protected on the wards and they’re much safer because they have so many different colleagues they can talk to. Junior doctors are often on their own. We try to take them under our wing, but there is only so much you can do. I often think about the ones I’ve known – the good ones – and hope wherever they are, they feel valued. Everyone should feel valued.

  The ward sister

  The night shift began just as the others had done.

  A handover in the little room with the plastic skeleton. The same doctor with the tired eyes. Claire, the Irish nurse. The exchange of bleeps and the passing on of jobs. My registrar never came to handover, but he was out there somewhere should I need him, moving around the hospital – dealing with the emergencies and making the difficult decisions, while I got on with the routine and the mundane.

  There were only a few jobs given to me, and none of them was urgent, so I sat for a few minutes and looked through a list at the patients I wanted to revisit, people I’d seen on previous nights and wanted to check on. A man with a grumbling high temperature on the male surgical ward. A woman on the second floor with a urine infection we couldn’t seem to shift. A dying woman in a side room on Ward 11, who had managed to hold on to another day and still remained on the list. I put the piece of paper in my pocket and made a start.

  It was just coming up to 2 a.m.

  Everything was going well. I’d just reinserted a cannula, for the third time, in a patient who seemed intent on pulling out all my glorious efforts the minute my back was turned, and I was going to make a pit stop at one of the vending machines when my bleep went off.

  It was A&E. It was most likely a new admission, or someone who needed their medication writing up, and I stopped at a phone in the corridor in order to call them. It was my registrar. This was the first time in three nights he’d got in touch with me.

  ‘Could you come down to the emergency department?’ he said.

  I couldn’t imagine what he wanted. Some registrars liked you to write in the notes as they spoke, or prescribe all the patient’s medication, but this registrar seemed happy to do all of those things by himself. Perhaps it was a big emergency, I thought. Perhaps it’s something important and he needs my help. I quickened my pace, fully expecting to walk into the scene of a major incident as soon as I pushed open the double doors to A&E. There was nothing. If anything, the department seemed quite peaceful. A couple of staff were restocking one of the trolleys and Claire was sorting out a medical bed for a new admission. She turned and smiled at me.

  ‘Everything all right?’ she said.

  ‘Yes,’ I said. ‘Yes, everyt
hing is fine.’

  I looked around the department and spotted my registrar sitting at the main desk, leaning back with his hands laced behind his head. He gestured to another chair and I sat down.

  ‘Everything all right?’ he said.

  ‘Everything is fine.’

  ‘Are the wards okay?’

  ‘The wards are fine,’ I said and I frowned at him.

  ‘I’m going to Amsterdam,’ he said.

  I frowned a little harder. He’d bleeped me to come all the way to A&E purely to talk about a holiday he had planned?

  ‘Right,’ I said slowly. ‘That’s nice, when are you going?’

  He leaned forward and smiled. ‘Now,’ he said.

  I waited for the punchline. There was none.

  I stared at him. ‘What do you mean, now?’

  He pushed something into my hands and I took it without looking down. ‘I mean I’m leaving now,’ he said. ‘You’re in charge.’

  There was a wave of anxiety so terrifying it pushed bile into my mouth.

  ‘You can’t just leave,’ I said. ‘I can’t be here all by myself!’

  He stood up. ‘You’ll be fine.’

  ‘But there’s six hours left of the shift!’

  ‘If I don’t go now, I’ll miss my flight.’

  He started to walk away.

  ‘You can’t just leave!’ I said again, only this time I shouted it.

  Claire, who had heard the whole conversation, shouted to him as well.

  He carried on walking. He even waved at us, without turning, like Liza Minnelli in Cabaret.

  He was gone.

  I looked down to see what he’d given me.

  It was a bleep. His bleep. The same bleep I was supposed to call if I was in trouble, or felt out of my depth, or needed help. The bleep everyone else in the hospital called if there was a surgical emergency.

  I held it in my hands.

  It belonged to me now.

  I had been a doctor for ten days.

  Within three minutes, the paramedics had arrived with an emergency, sirens and lights and a crash of doors. My registrar must have driven right past them on his way out of the hospital car park.

  It was a young man with severe abdominal pain and vomiting. He also had learning difficulties. He had a long and tricky cardiac history, and multiple other health problems running alongside, and if that weren’t enough to make things complicated for him, and also for us, he had a permanent tracheostomy. He was in severe pain. He was understandably frightened and he was thrashing around on the trolley, kicking and punching each time anyone went near him.

  The A&E consultant shouted from somewhere in the middle of a crowd of people.

  ‘Where’s the surgical team?’

  I felt the weight of the bleep in the pocket of my scrubs and I took a deep breath and swallowed back the bile.

  ‘I am the surgical team,’ I said.

  I watched from the corner of the Resus room as the A&E staff stabilised him. They monitored his heart and his breathing, they got his pain under control, and they managed to calm him enough to examine him and take bloods. I watched in awe at their skill and their expertise, at their kindness and understanding, but also with a huge weight of guilt and deep anger that this young man was not getting the surgical doctor he was entitled to. He was never put in any danger and he was never neglected, but he deserved better than me. At that moment it felt like every patient in the hospital deserved better than me.

  The A&E consultant walked over to where I was standing.

  ‘He needs an ITU bed,’ she said and looked at my badge. ‘Where is your registrar?’

  ‘Amsterdam,’ I answered, because there wasn’t really anything else I could offer.

  ‘I’ll get him an ITU bed,’ said a voice from across the room.

  It was Claire and she did exactly that.

  I watched the young man being taken away by the porters. He also had a nurse and an emergency department doctor with him, and his trolley was littered with so many wires and so much equipment that it was difficult to tell if there was a patient lying among it all.

  The sense of relief made my legs unsteady. He belonged to someone else now – someone far more capable than I was – and I could go back to my own job, because, while the registrar’s bleep had stayed eerily silent while I was in Resus, my own bleep had gone off so many times that some of the numbers couldn’t be stored and they were erased forever. It wasn’t a problem. There was no doubt in the world that they would bleep me again.

  I worked my way through the phone calls, prioritising jobs, talking to nursing staff. All the time I thought about the young man and I wondered how he was doing. Ten minutes later, my bleep went off yet again. It was ITU.

  ‘This is the on-call doctor from ITU. We have your patient,’ said a woman’s voice.

  She put a particular emphasis on ‘your’.

  I hesitated. ‘Yes,’ I said.

  ‘I just wondered,’ said the doctor, ‘would you like me to prescribe all his regular medication?’

  I hesitated again. Would he be having surgery tomorrow? Was any of his medication inadvisable if he was? What about the drugs he had in A&E – did any of them mean he shouldn’t have his regular medication alongside?

  I didn’t know. All of it would be written in his notes, which were now in the hands of the doctor who was calling me. This doctor also happened to be an ST5, and, in the strangely labelled hierarchy of doctor training, that meant she was at least five years more experienced than me.

  ‘I don’t know,’ I said.

  She put the phone down.

  Ten minutes later, she bleeped me again.

  ‘Would you like me to put a nasogastric tube down?’ she said. ‘To feed him?’

  There was silence. It felt like an exam.

  ‘Does he need a chest X-ray?’ she said.

  Still silence.

  ‘He has a tracheostomy, is a chest X-ray still necessary?’

  ‘Yes,’ I said, but I turned it into a question.

  She put the phone down again.

  This went on through the night. Every twenty minutes I would be bleeped with a question or to tell me a pulse rate or a blood pressure reading; to ask me what she should do, even though her experience meant that she was more aware than I was of what was needed. When she had drawn out my ignorance and highlighted my complete lack of knowledge, she would replace the receiver without speaking. Clearly, this woman was having just as bad a night as I was, but it felt like I was being punished. It felt like bullying.

  Twenty minutes later, my bleep went off again. I presumed it was my next set of impossible questions, my next round of punishment, but it wasn’t. When I checked the number, it was one of the wards.

  ‘Can you come to Ward 11?’ said the nurse. ‘Can you come straight away?’

  It was the woman in the side room, the one on my list who had held on to life for another day. At five o’clock on an August morning, her body had decided it was time to leave.

  It was not an easy journey. The cancer she had endured had marched through her body, taking her organs one by one, burrowing deep into her bones and spreading itself throughout her brain. She had pain relief and anti-nausea medication prescribed, drugs to help with her swallowing and her anxiety, but it wasn’t enough. I could hear her cries as I walked down the corridor towards the ward.

  ‘Could you give her some more morphine?’ said the nurse.

  I looked at the woman’s drug chart. She was almost up to the limit of what I was allowed to prescribe, but I could risk a little more.

  We waited in silence, the nurses and I, sitting in pools of light made by the night lamps on the desk. The crying continued.

  Let me die the woman shouted from the side room, please just let me die.

  We waited. Perhaps it needed time to kick in.

  Please just let me die.

  ‘Can’t you prescribe any more?’ the nurse said.

  I solemnly pledge to c
onsecrate my life to the service of humanity.

  I looked at the drug chart again. The woman was on the maximum dose allowed. If I wrote up any more, not only would it be illegal, it would look as though I had deliberately put an end to her life. It would look as though I’d killed her. Her relatives were on their way, what would they think if I prescribed too much? What would they think if I didn’t?

  ‘I can’t,’ I said. ‘I’m not allowed to.’

  Please just let me die.

  ‘Where’s your registrar?’ she said.

  ‘He’s gone to Amsterdam. He’s disappeared in the middle of the shift and left me. I don’t have anyone else. I’m on my own.’

  ‘Then it’s down to you – she needs more pain relief.’

  Please just let me die.

  I stared at the drug chart. What should I do – should I stick to the rules or should I write up the morphine and face the consequences later? If this was my mother, wouldn’t I give her all the morphine in the world, just to put an end to her misery? Was I putting myself and my own survival before the needs of a patient?