Breaking and Mending Page 9

  I will practise my profession with conscience and dignity.

  We rang Claire and a few minutes later she appeared on the ward. She was authorised to prescribe a little more.

  ‘This is all we can give,’ she said.

  It didn’t do a thing. The crying continued. It was like nothing I had heard before – brutal and desperate, and drawn from a place I could never begin to understand. The final cries of someone who needed a release that no one, even with their training and knowledge and ability, was prepared to give to her. This was something they don’t teach you at medical school, something you only understand when you have walked through it; something you can never un-hear, because I knew, as I sat there in a pool of light at the nurses’ station, I would remember that voice for the rest of my life.

  ‘I can’t stand this any more.’ The nurse got up and walked away.

  I will maintain the utmost respect for human life.

  I made myself stay. I made myself sit in the chair closest to the side room and I forced myself to listen, because I knew I would always need to remember the sound of my own inadequacy. Woven into a doctor’s sense of self is the need to revisit our own failures, to return to a memory again and again, so that it never loses its colour and its brightness, so we will forever have to hand a reminder of our own flaws and incompetence. Perhaps it tethers us to the limitations of medical knowledge, and our own skills, and stops us from floating away on a fantasy of the person we would like to believe we are. Perhaps it does none of those things and we just feel comforted by the reminder that we are only human. Perhaps, in the end, it makes us better doctors.

  It was 5.30 a.m and it would be several hours before anyone more senior arrived at the hospital.

  ‘We need to ring the on-call consultant,’ said Claire, and she passed me the telephone.

  The voice on the other end was sleepy and faint, but very clear.

  ‘Prescribe as much morphine as you need to make her comfortable,’ she said. ‘But write in the notes that we’ve had this conversation and the time that we had it, and write very clearly that I’ve instructed you to do so.’

  Within minutes, the crying had stopped. I listened into the silence, but there was nothing. The woman slept peacefully, her breathing slow and steady. I looked at her face and I wondered where she had gone to.

  One of the younger nurses on the ward sat next to me and watched, pale and tear-stained, as I wrote in the notes.

  ‘I will never forget this night,’ she said.

  I looked up from the page. ‘Nor me,’ I said. ‘Nor me.’

  I was just leaving when my bleep went off again. It was the doctor from ITU.

  She read out a list of observations, needle-sharp, on my patient. Blood pressure, pulse, respiration rate, urine output.

  I listened to her in silence.

  ‘What would you like me to do?’ she said.

  I felt a tired rage grow in the well of my stomach. It made its way through my body, flowing through my legs and my arms, filling my head and my eyes and stretching right to my fingertips. I gripped the telephone so tightly, I was worried it would break.

  ‘My registrar walked away from the shift in the middle of the night. I am carrying a bleep I should not be carrying. I’ve just spent the last hour listening to the cries of a dying woman and there was nothing I could do to help her. I have been a doctor for ten days, so what I would like you to do,’ I said, ‘is to leave me alone. What I would like you to do is to stop bleeping me.’

  I put the telephone down. She didn’t call again.

  I took a journey through the hospital. I chose the longest route, because there are times when your unhappiness and self-loathing is so great there is nothing you can do except try to walk as far away from it as you can.

  While I had been on the ward, time had crossed over the second when night becomes day. I could hear the whir of floor cleaners somewhere along a corridor and the rattle of breakfast plates in a kitchen. Porters moved between wards, nurses crowded into offices for handovers, and the next shifts began. The hospital had turned around me and everything else had become clean and new again, leaving me to walk the corridors wearing yesterday’s thoughts. It was as if the previous night had never happened, as if the whole thing had been imagined – constructed from my own worst fears, crouched hiding in the corners of my mind.

  At eight o’clock my shift ended, and I waited by the staff entrance to the hospital. I watched everyone arrive for work. Doctors mainly, a great sea of them, pouring through the doors and into the corridors.

  ‘Where were you,’ I thought, ‘a few hours ago? Where were you when I needed just one of you to be here?’

  Eventually, I spotted him. My consultant. Smart and suited. Overcoat and briefcase. I stood in his path and he slowed his pace until he was standing right in front of me. He stared.

  I handed him the bleep.

  ‘What’s this?’ he said.

  ‘This is the registrar’s bleep and I have been carrying it for the past six hours.’ I could hear my voice falter and break. ‘Your registrar left me in the middle of the shift. He went to Amsterdam. I have had no registrar support or supervision since two o’clock this morning.’

  I expected outrage.

  I expected I’d have to stay beyond my shift and make an official statement, to put something in writing. I expected repercussions, perhaps even an inquiry. At the very least, I expected a reaction.

  There was nothing.

  ‘Did anything …’ he paused, ‘… untoward happen?’

  I hesitated. What would he define as untoward? No one had died. Everyone had received the care they needed, eventually. But I thought about the young man in ITU. The woman in the side room on Ward 11. They deserved better, they deserved a doctor who didn’t vanish in the middle of a shift.

  He took my hesitation as a no.

  ‘Then I don’t know what you’re bloody complaining about,’ he hissed, and he put the bleep in his coat pocket and he walked away.

  I stared after him. One of the nurses from the ward was standing next to me. She was leaving after the shift, a raincoat over her arm, a bag on her shoulder. She leaned forward and whispered in my ear.

  ‘He already knew,’ she said.

  I watched the consultant walk further down the corridor and, in that moment, I realised I was on my own. I was no longer in the safe embrace of the medical school; I was in a job now and this was not a job in which you spoke out. This was a job where the rules were defined by the players and I was clearly expected to keep my head down and my mouth shut. The lines had been drawn around me and, whether I chose to cross them or not, those lines would determine whether I sank or swam.

  I knew all of those things because, as I watched the consultant walk away and I saw the arrogance in his step, the way he laughed and waved to one of his colleagues across the corridor, the way he didn’t even give me a backward glance, I knew that the nurse was almost certainly right.

  He had known all along.

  Roles

  The hospital ebbed and flowed and I allowed the undercurrent to take me. After that night shift, it seemed easier to be carried along by jobs and bleeps and telephones each day, rather than be prisoner of my own thoughts. The ward rounds and the rotas, the pressure and pull. I tried to stay at the edges, to do what was expected without allowing it to take ownership of me, but eventually this proved to be impossible.

  All the way through medical school, the one thing that keeps you going, despite the exams and the travelling, the lack of money and the complete absence of free time, is the idea of what kind of doctor you are going to be. You don’t fantasise about prizes and awards and accolades, you imagine the small and the ordinary instead. Having time for your patients, being able to explain a treatment to someone in a way they can understand, helping someone’s journey to be a little more bearable. It’s only when you arrive on the wards, when you are spat out into an NHS that bends and breaks under the strain of the endless demands
placed upon it, it’s only then that you realise you will never be able to be the doctor you want to become.

  The system simply won’t allow it.

  Instead, you will carry three bleeps because no doctors applied for the jobs next to yours on the rota. Instead, you will trip over your own misery, as you attempt to keep up with everything you are asked to do. You will watch patients drift past each day who are clearly unsure and afraid, but there will be nothing you can do about it. Relatives wait for reassurance, but go home empty-handed. Waiting lists are full. Clinics are crowded. Everyone pushes and fights and shouts to be heard above the noise of other people’s agony. Rights become privileges. Equality becomes discrimination. Time, money, resources and hope all run dry. The NHS is held together by the goodwill of those who work within it, but even then it will fracture, and you will fall into the gaps those fractures create, and you will disappear.

  You quickly find that you can never be the doctor you wanted to become, because the doctor you wanted to become would not be able to survive.

  As you move with the current that ebbs and flows, you occasionally find yourself washed up in a place where there’s a chance that you might make a small difference, and when this happens you fight very hard to hold on to that chance. Perhaps it helps to balance out all the times when the system forces you to walk past, when you have to turn away because the disempowerment you feel is too much to stomach. You reach out with both hands for such opportunities, even if it means that, by doing so, you have to let go of another tiny piece of yourself.

  My chance to make a small difference was called Joan. She was seventy-nine. She had learning difficulties and was blind, and she wore a very powerful hearing aid, which Joan was very selective about using, depending on the topic of conversation and whether it suited her or not. As if life hadn’t thrown enough challenges at Joan, it had recently been discovered that she had inoperable cancer. It wasn’t something Joan wanted to know about, and each time it was mentioned, she would very deliberately turn off her hearing aid and disappear away into another corner of her mind. Joan’s younger sister – who was a sprightly seventy-four – was left to make all the decisions and to deal with Joan’s infamous temper and tidy up all the pieces of her life, and I think this was probably the way it had been ever since they were children.

  Joan was in a side room on a ward at the very top of the hospital. All patients are equal, but some are more equal than others and I fell for Joan immediately: for her feistiness and her independence, her refusal to let all of these challenges get the better of her. I fell hook, line and sinker. I thought she was wonderful.

  After my shift had ended, I would call to see Joan. She had refused any palliative treatment – no chemotherapy, no radiotherapy – and she waited, as many older patients do, in a grey limbo for somewhere else to go. Joan needed a nursing home, but her needs were great and very specific, and all the nursing homes we tried didn’t need a Joan. Each afternoon, I would stand by the door of the side room and call my name, and Joan would let me know if I was allowed to come in. As time went on, I was never refused.

  Joan had never learned Braille, so I read to her from books and magazines. I described the world from the windows of her side room. I brought her chocolate from the hospital shop and I was told off for buying the wrong kind. I made tea (too sweet) and coffee (too bitter). I was always either too late or too early, but my company was never turned down. I got to know Joan’s sister, and whenever the two of us talked, Joan would take great pleasure in disagreeing very loudly with anything either of us said. I adored her.

  One day, I was on the ward for something else and I stood outside Joan’s room and called out my name. There was no answer. There was always a ‘come in’, or very occasionally an invitation to clear off, but there was never no answer. I peered around the door. Joan sat next to the bed. The radio, her usual companion, was silent. Her head was bent, but she wasn’t asleep, and I went over and said her name. Nothing. I crouched down and held her hand in mine. She squeezed my hand back, but still she didn’t say anything. Was it the cancer? She didn’t seem to be in pain, but was she depressed?

  I was concerned about Joan all day. Even as I talked to other patients and sat through meetings, I couldn’t stop thinking about her. When I returned to the side room in the afternoon, Joan’s sister was there, and before I could get out my giant ramble of a worry, she said: ‘It’s Joan’s hearing aid – it’s stopped working.’

  Of course it had. It was a junior doctor’s schoolboy error – the patient was failing to answer simply because she couldn’t hear, and the loss of her hearing aid had trapped Joan in a noiseless, sightless world with only her own thoughts to keep her company.

  ‘The nurses haven’t had a chance to get it fixed, they’re rushed off their feet.’

  They were. The nurses were just as pressured as the doctors, trying to hold a ward together on goodwill and with half the staff they actually needed.

  ‘I’ll go,’ I said.

  I had never been to audiology, but I’d seen the signs many times as I walked the corridors. The offices were up several flights of wooden stairs, which became increasingly narrow the higher you climbed, and when I finally reached the reception desk I was all out of breath and more than a little flustered. I had to talk my way through five people before I found the man who mended the hearing aids.

  ‘And you’re a doctor?’ he said. ‘We don’t get any doctors up here.’

  I thought back to being a medical student, when I’d changed a patient’s urine-soaked sheets because there was no one else available to do it (and surely anybody else would have done the same). What exactly said my registrar is your role here? Three years later and I obviously still hadn’t found an answer to that question.

  ‘My shift ended ages ago,’ I said to the audiologist. ‘There’s a first time for everything?’

  I tried to do a little laugh, but he just frowned.

  They mended the hearing aid while I waited.

  I returned the hearing aid to Joan, and she told me off for fumbling around and not putting it in properly, but then she was back. All smiles. She had found us again. We could go back to our bars of chocolate and story reading.

  ‘I’m so glad you sorted it out,’ her sister said, as we walked in the corridor outside. ‘They’ve finally found her a nursing home and it would be so complicated to get it done from there.’

  ‘They have?’ I stopped and turned to her. ‘When does she leave?’

  It had all been arranged very quickly. Joan would be discharged the next day. It was good news, of course. In the small amount of time she had left, it would be far better for Joan to be settled, to be away from the hospital and the risk of infections and isolation. I just couldn’t imagine anyone else being in that side room.

  ‘We’re not telling her until just before she leaves. She’s always hated change.’

  My shift had long since ended. By some quirk of the rota I had the next day off and so, after I left Joan and her sister, I wandered around the hospital tidying up loose ends. Typing a discharge letter. Filling out bloods requests. I decided that I might as well and so save someone else the job tomorrow. I sat on different wards and chatted to nurses. I wandered around A&E to see if there was anything interesting going on. The on-call doctor spotted me a few times and looked at me in a curious way. When I checked my watch, it was almost eight o’clock and I thought that it would make more sense to eat in the canteen rather than cook something when I got home.

  I sat with my melamine tray at one of the restaurant tables and stared at a plate of untouched food. What was I even doing there? I usually couldn’t wait to finish my jobs and get out of the place, yet I was still here three hours after I should have left, and trying to find another excuse to stay. It took me a moment to realise it, but when I did, it hit me with such clarity that I couldn’t believe I hadn’t seen it sooner.

  It was Joan. I knew that by the time I came back to work on Monday she would be go
ne and I didn’t want to leave her. I didn’t want to say goodbye.

  I got up from my plastic seat and my melamine tray of untouched food, and I walked to the ward.

  An evening ward and a daytime ward have very different personalities, and by the time I arrived, all the visitors had left and the patients were settling down for the night. The drugs trolley was making its way around for the last time. Curtains were closed around beds. Nurses sat at computers, typing out the day into keyboards.

  I could hear Joan, even as I walked down the little corridor to her side room. She was complaining about the laces on her shoes and I smiled, because there is nothing more reassuring than hearing a patient grumble about something. Very ill patients never complain.

  When I poked my head around the door, one of the healthcare assistants was trying to remove Joan’s shoes and she looked up at me and smiled. Joan sat on the edge of the bed with her back to me, which didn’t make any difference of course, but did somehow make it easier. I looked at her tiny frame, the sloping shoulders and the whorls of white, ice-cream hair, and I tried to make sure that I could always remember this and keep it safe.

  The healthcare assistant moved on to Joan’s cardigan and Joan moved on to complaining about buttons, and the HCA and I smiled at each other again.

  ‘Goodbye, Joan,’ I whispered, knowing she wouldn’t hear. ‘Travel well.’

  And I turned around and I left.

  When I arrived back at work on the Monday she was gone and her name had vanished from the patient list.

  I didn’t have any reason to visit that ward, because Joan had been an ‘outlier’ – a patient placed on a different ward in a different part of the hospital, because there were no beds available in the usual places. A couple of weeks later, though, I found myself up there again. A different patient. A different outlier.

  I was just leaving when one of the nurses called me back.

  ‘I have something for you,’ she said, and she reached into one of the drawers in the nurses’ station.