Surgery takes a long time to learn. Five years of medical school are just the lead-up to an apprenticeship which usually runs into decades. Of course, there are lots of facts to remember, and cutting people is a craft best acquired carefully. But the length of training serves another important function. It ensures that, by the time you have any real responsibility, you aren't young any more. This getting old makes you more aware and therefore safer.
When I first went to medical school, I only had to imagine myself as a surgeon to feel a self-congratulatory thrill that lasted the whole day. I felt capable and couldn't wait to be given some control. Thankfully, this cocky time was brief. I soon discovered the full extent of my uselessness.
At the end of my first week at medical school, I stopped by the anatomy department on my way out to meet friends for the evening. I was there to collect a skeleton, mine to look after for the next two years. The cardboard box which held it was about a metre long, big enough to hold a femur. And about nine inches wide and nine inches deep. Inside was a skull, its jaw newly attached to the temporal bone by a tiny spring. You could hold the head in one hand and make the teeth go clickety-clack. And there was a spine, all the vertebrae strung together like beads. And then there were all the bones from one arm and one leg. The individual bones of the hand and foot were wired in place like the vertebral column. But overall, these bits were loose so that every time you moved the casket they found new macabre arrangements. I couldn't wait to introduce my old acquaintances to this desiccated new one.
The size of this container suited my pride in it, its lightness my joy. I took it from the medical school and onto the Tube. I glowed. I wished it was transparent or that it said 'skeleton' on the side. I wanted total strangers to invite me to reveal my occupational identity, I felt so excited to be doing this wonderful thing with my life. I completed my whole journey with no human interaction. Even giving the box its own seat next to me had not prompted curiosity. I picked up pace, therefore, at the prospect of meeting my friends, who I knew would take an interest in my show-and-tell parcel, whose interest would frame and set my choice of career.
I arrived at the pub and saw none of my friends were there yet, so I went straight to the busiest part of the bar, put my ignored charge on a stool, and ordered myself a drink. At this stage, I was hoping a stranger would chat me up so that I could divert his questions to my precious cargo. A middle-aged couple approached me instead. They paid for my drink and asked me to join them while I waited for my friends to arrive. I moved swiftly from pleasantries to the fact that I was a medical student to the proud proclamation that I was now the responsible guardian of a skeleton, real bones. I was all ready to shake the box so that it would give a tempting low rattle. I wanted to grasp the sides of its lid and let the top shudder from the bottom.
Just then, there was a commotion on the other side of the pub. The man I had been talking to went round to see what had happened. He looked like he would be good at sorting out a brawl. Almost immediately, though, he rushed back round to his wife and me. His T-shirt had come untucked from its tethering in his below-the-tum jeans. His belly showed hairily and his eyes looked like balls, not discs. He didn't know my name so simply exclaimed, 'Medical student! Come quickly.'
I followed him round. I saw a man lying on his back on the floor. He was still and straight. He looked like he was performing something. A magic trick. Or measuring an empty floor in a house he was about to buy, to see if his double bed might fit there. His hair had fallen with him and was not strewn from him. He had jolly socks on and his eyes were open.
A man I didn't know said, 'He was going to the bar and he just suddenly fell down like that. He's not breathing. I think he's dead.' I didn't know why he was talking to me, and was about to add my own non-sequitur and say, 'No, I don't know him either,' when I realised that a small crowd of people had gathered and that the couple I had made friends with were explaining that I was a medical student, without adding what I had not bothered to mention, which was that I had been in training for less than a week. Without telling them what I hardly knew myself, which was that I knew nothing.
I felt big, with everyone looking at me. I was a training doctor. How lucky that I happened to be in the pub that evening. With a complete lack of self-awareness, I kneeled by the man's head. I put my index finger against his neck to feel for a pulse, which at that time I didn't even know was the carotid artery. I also bent my ear to his mouth and indeed heard and felt no breath come from it. 'Call an ambulance,' I said, before sitting back on my haunches. I had no more knowledge of resuscitation techniques than anyone else in the pub. I sat there for some time. There was still no sign of my friends.
Then there was a siren, and lights flashing through the bottle-green pub windows and alert, strong men moving people aside and approaching the moribund man with their casks of oxygen and contraptions. A mask was fitted to the unconscious man's face, with a ventilation bag attached to it. A man in a green boiler suit began chest compressions. Cold air coming through the double pub doors and activity perked everyone in this dopey room up, except the one they were working on. They put the man on a stretcher and they were on their way out when my acquaintance announced to the paramedics that I was a medical student and that I had been fantastic. The green practical man looked at me quickly with what I took for a sort of recognition, gave me the bag and told me to squeeze it, as he had been doing.
Then we all went outside and, because I was still pressing the bag in what I hoped was the right way, there was nothing else for me to do but climb with the others into the back of the ambulance. I did think of my skeleton left behind. And my handbag. But these things didn't matter now. The rear doors had clunked shut. One! Two! And the ambulance was pulling away from the kerb. One of the green men was driving. The other was in the back with me. And the mottled man was in the thick of it all.
The journey was short. My first ever ambulance, no longer closed to me like the confessionals of Larkin's poem, lurched and smelled. I was facing backwards and there were no windows to look out of. Then we were at the hospital, the doors opening onto the cold scent of wet car park. I was still squeezing the bag at the head end of things. I needed to concentrate so the bag wouldn't fall off the man's face as we hurried into A&E. Next, I was inside my first ever resuscitation cubicle. Someone whisked the green curtain around us, and a whole new set of efficient people did things. A nurse put a lead jacket over my head. This reminded me of one of those painting pinafores you wear at nursery school when you are going to do a picture on an easel. But it was heavier because it was full of lead to protect me from any X-rays that might be taken.
I was impressed by the fact that there was very little talking despite the number of people and all the action, and I felt at the heart of this team. Efficiency and neatness often go together, but here they didn't. Two people vied with each other to get quick intravenous access. Each held one of the patient's arms straight and pushed needles into its soft fold, the antecubital fossa. Blood meandered down the man's arms and made tiny splashes of bright red on the grey lino floor. The mess was like snacks at a drinks party. On the counters were kidney dishes piled with bloody gloves, and plastic boxes laden with sharps and venflon stickers. And the landscape of the patient himself had changed too. His shirt was open and he had vomit on his neck. Cardiac stickers made a pin-the-tail-on-the-donkey map on his chest, and he had tubes protruding from him. It was odd to think that this cubicle had recently been clean and empty.
The patient still hadn't woken up, but the activity gave his very lifelessness a sort of momentum. Adrenaline and atropine, pushed in aliquots into his cannula, were part of this relay of hopeful assaults, as were brief periods of chest compressions and triple serves of defibrillation. Someone put electrical paddles on his chest and the team leader said, 'All clear, oxygen clear, ready,' and everyone moved backwards, reminding me of the stepping-out part of the hokey-cokey or the way a cast all step back before they take their bow at the end of a play. But our patient did not applaud us by recovering. At a certain point, the consultant asked each one of us if we were happy to stop and the flurry of attempts to save this life ceased. There wasn't a reverential hush like you see on TV, with everyone looking meaningfully at each other. Rather, the activity that had seemed to be about making a mess, was now directed towards clearing up. Yellow metal rubbish bins clapped their pedalled clap. Gloves came off. A nurse mopped blood and sick off the patient like she was cleaning a messy child. The consultant came over and told me the paramedics would take me back to where they had found me.
I sat between them in the quiet, slow ambulance, feeling a poignant and not unsatisfying sort of sadness, and they took me back to the pub where last orders were in, and my friends were waiting for me. My skeleton was there too, and looked inert to me now. It was only when the hopeful bartender asked me how things had gone, and I saw his disappointment at my answer, that I realised something that had escaped me in A&E. Namely, that I had enjoyed the show but contributed nothing. A few months later, a little more informed, I would realise that the only person who had had the opportunity to save that man had been me, in the moments after he had collapsed. I had not even known basic first aid, so had squandered the chance and a life. I didn't ever feel quite so proud of being a medical student after that.
Over a number of years, and with the passage of many deaths, I left this keen but ineffective self behind. Seamlessly, I began to make myself useful. Each hospital job brought new levels of responsibility, minute increases in status within the overall structure of things. And then one day, I realised I wasn't a junior doctor any more; I had risen significantly in the hierarchy and become a registrar. This happened one summery week, when the leaves on the plane trees around the hospital brushed together softly like so many pat-a-cake hands. At the end of the interview when I got my job, I was told I would do my first on-call as a registrar the following morning.
I rose early that day. Instead of putting on the theatre scrubs which I had always worn for weekends on call as an SHO, I chose the suit I had used for my interview. I also packed a briefcase, instead of my old backpack. I had been given it by my parents at Christmas the year before, and had mistakenly taken it into work once to be met with ridicule by my junior colleagues, for getting ideas above my station. This morning its stiff click seemed to fit.
I arrived on the ward and was greeted by one of my surgical friends. He and I had been SHOs on this very ward for the past year. He had also been amongst the dozen or so at the interview the day before, competing for the job I now held. I thought how odd it was that a chasm had opened between us in terms of seniority although there was no difference in our knowledge.
He reached for the notes trolley, which the most junior person on the ward round rolls from bed to bed. It has a little fold-out table for leaning on when writing. The metal sides are grey and tubular like the sides of boardingschool beds. They have thick shiny paint on them, so much that you can see rivulets of dry paint that was once wet. I know the feeling of gripping this surface like I know the feeling of wearing a bra, so that you're not aware of it any more. The table edge rests against your belt and you put the tubular sides in your hands and have to swerve it largely as you do a heavy supermarket trolley to get it to go where you want it to. He did this. He knew the map of the patients. His list reminded him of their date of admission, their presenting complaint, their progress.
As we stopped at each bedside, I had to keep reminding myself to behave like a registrar, to stand a little aloof and let my SHO do the chores. Perhaps a little posturing was all that was required. Certainly, it all seemed easy enough. The first several patients had tonsillitis or nosebleeds, or were recovering from the previous day's general ENT list. I had seen other registrars lay out simple plans for these things many times.
But then I came to a bed where things didn't seem quite right. The patient was a man in his fifties, with a strong build. His beard was gun grey and densely cut like a hedge. He was looking at The Economist, which lay on his lap, but his hands were pushed down next to his hips, splinting his chest to make his breathing easier. His respiratory rate was elevated. He wasn't complaining, but his posture was.
Daniel filled me in. Mr Charles, fifty-six years old, admitted with sore throat the previous night. Past history of tonsillitis. Unable to eat and drink. IV antibiotics and steroids given. I asked him how he was feeling. 'Not so bad,' he said but even these few words made him a bit breathless. He wanted to keep his arms pressed down and his hands made quilty pits in the mattress. To talk to me he just lifted his eyes up, keeping his face down like coy girls do.
I took the notes and flicked through what had been written during the night. I found the script I was looking for. FNE: NAD. Flexible nasendoscopy: no abnormality discovered. Unsure of what to do next, I asked Daniel to fetch me the scope so I could have a look myself. This piece of equipment is about eighteen inches long. One end is an eyepiece, the rest is like a thin black snake made of fibre optics. The bendy bit is put inside the patient's nostril. The other end is held in the doctor's dominant hand. You hold it to your eye and look into the eyepiece. There is a little ridge on the top of this which your index finger can move up and down and this makes the snaky end move up and down inside the patient. You can look at all the dark crannies of the nose's interior. But you can also push it much further down and look at the vocal cords.
I passed the scope into Mr Charles's left nostril and entered the internal landscape of his nasal cavity. His septum lay on the left like a great straight wall, and on the right were his turbinates, like plush cushions in the corner of a dodgy nightclub. I negotiated the scope's tip over the inferior turbinate and under the middle one, noticing a rivulet of mucus coming from the entrance to the left maxillary sinus, as big as a waterfall. I went to the end of the nose, and then used the button on the eyepiece to make a ninety-degree downwards turn. Like a pot-holer, I advanced past the nasopharynx, a shady chamber flanked by the wonderfully named Caves of Rosenmuller, where nasal cancers sometimes hide. At this point, you usually come into the clearing of the hypopharynx and then see the larynx which looks like a teeny, tiny vagina.
On this occasion, though, I did not come into the customary clearing. I reached the nasopharynx but seemed unable to go further. I pulled the scope backwards just a little then tried to advance again. The same. In front of me was a wall of pink mucosa, swollen, cushiony, bright. I thought I must be banging into the adenoid or the posterior pharyngeal wall. Again, I tried and failed to make progress. Fleetingly, I wondered if my patient might be losing his airway. But this didn't make sense. If Mr Charles was in dire straits, it would surely be more obvious. Wouldn't he at least have stridor, that strained wheezy whistling you hear when someone is fighting to take in or let out breath through an obstructed airway? Wouldn't he be looking blue?
I felt instinctively that my patient was too well for this to be happening but also remembered something I had been told in my junior-doctor year that I had never since forgotten. Namely, if it crosses your mind that something might be wrong with someone, do not ignore the thought. If what crossed your mind kills your patient, you will never forgive yourself or be forgiven.
These thoughts were in my mind, and my right eye was still up against the eyepiece, looking at Mr Charles's hypopharynx. In the two or three seconds it took me to ease the apparatus backwards and out of his nose, I had decided that I was going to have to call the registrar at home and ask him to come and have a look himself. So, when my view returned to the more general reality from the small significant geography it had been fixed on, I was surprised to see my suit on my legs, my briefcase by the bed, my SHO at my side, all of which reminded me of the obvious fact – amazingly forgotten – that the registrar on call that weekend was me.
As recently as the day before, if I had encountered a crisis of confidence about something, I would have shared it with the doctor standing next to me, my friend. But in this hyperaesthetic moment of discomfort, I felt that if I let the doubt that was in me out of my mouth and into the air, I would unravel. To buy myself a little thinking time, I said to the patient that I wanted to take the scope to a pot of sterilising fluid round the corner and then I'd come back and talk to him. I left the two men there and went into the sluice. I put the scope's long tail into a jug of sharp-smelling fluid and wrote the time on the piece of paper next to it so that whoever needed it next would know if it had soaked for long enough. Two different voices sounded in my head. One said: no one else was looking down that scope at that red realm but you. The examination last night was normal. The patient does not have stridor. He's probably fine. If you walk off the ward now, no one will know that you don't know what to make of what you saw. If the patient gets worse, you can always come back.
The other voice placed me back in the interviewing room where I had won my registrar number. I imagined myself being asked a question by one of the consultant interviewers. 'You are doing your first on-call as a specialist registrar. On the ward round, you see a man with a sore throat who does not show any overt signs of distress. But when you scope him, you cannot find any airway. What do you do?'
Immediately, I saw myself in my mind's eye, saying, 'This is an airway emergency. There is no time to lose.' And with that, I stepped back into the real world, like Mr Ben coming back from his dressing room into the shop. I returned to Mr Charles's bedside. I explained to him that, having looked down his throat, I was concerned that he might not be suffering from tonsillitis after all, but instead something more serious called supraglottitis. That I was concerned that if things became any worse, his throat might swell to the point where he wouldn't be able to breathe. I went on to say I wanted to take him to the operating theatre so that we could examine him under anaesthetic. We would probably put a tube down his throat and leave it there for twenty-four hours while we gave him medicine to reduce the infection and the swelling. I added that there was a chance he might wake up with a tube sticking out of his neck if we were unable to get one down his throat.
Mr Charles was laconic. Perhaps this was his nature. Or, perhaps this was just how a man who was about to suffocate would be. I used his muteness as an opportunity to call my consultant, who agreed to come in and stand by in the operating theatre in case an emergency tracheostomy was necessary. I also called the theatre nurse who put our case at the top of the weekend's emergency list. My junior colleague had succeeded in calling the anaesthetic registrar who was going to call his consultant in too, in case he found this airway a particularly difficult one to bypass.
By now, my private doubts were making me feel ill. I had perfomed an uncertain nasendoscopy. I wasn't sure at all that my patient was losing his airway. Maybe I had just examined him incompetently. There were two consultants on their way into the hospital during the weekend. Another doctor, the anaesthetic registrar, was probably waiting in theatre. Other emergency surgical cases would be postponed because of my hunch. There was no middle ground here, no spectrum of grey. Either the patient was completely fine, or his life was in immediate danger. If I was wrong to draw attention to this, my reputation would never recover. If I was right, I would have saved a life. Nowhere in this internal monologue was concern for the patient's welfare in evidence.
My sense of unease sharpened while I sat at theatre reception to wait for everybody to arrive. In front of me was the red ringbinder that held the day's emergency list. I opened it and looked down to see the last entry which was ours. Examination under anaesthetic airway. Plus or minus intubation. Plus or minus tracheostomy. Next to it was an arrow showing that our procedure should go before the one on the previous line. This line said 'Kidney Transplant'. As I read this, I felt the red folder I was holding open do a little jump on the beige grainy Formica counter and looked up to see that this had been caused by the banging down of a big square metal box which had a fluorescent pink label on the side, and that label said two things which were 'FRAGILE' and 'KIDNEY'.
Nothing could have made me feel more oppressed than this. Sitting next to this kidney on ice. A kidney that would have to wait to be plumbed into a needy abdomen because of what now felt like a whimsical doubt on my part about the patency of someone's airway. The next thing that happened was that everyone turned up at once. The patient, looking disconcertingly well on his trolley, led by a porter in his navy trousers and matching T-shirt. The two anaesthetic big-shots in their blues. My consultant, who breezily said, 'What's going on then?' as he wheeled an expensive black-framed bicycle into theatre reception. He was wearing an all-in-one cycling suit and had on his back one of those rucksacks that have a hidden tank and deliver water into the athlete's mouth via a tube. This tube was positioned near Mr Millard's mouth like a bizarre microphone. He was all excited from exercise and urgency. His activeness and readiness for more action made everything sink lower and lower inside me.
Like lambs to the slaughter, I thought grandly, the patient and I. He with his life on the line, me with my nascent reputation. We were soon in theatre. The anaesthetists were gassing Mr Charles down slowly while Mr Millard and I scrubbed and checked we had everything we needed on our trachy tray. I was grateful for the cover of my mask and gown for I had started to sweat and a blush of fear was rising and falling from my neck in sickening waves. Hot. Cool. Hot. Cool. As the anaesthetic registrar flicked open his laryngoscope with its curved metal tongue, and bent forwards over our supine charge, my only prayer was that Mr Charles should be in real trouble, about to die, even. Anything but OK. Let his airway be sick, I thought. Do not let that tube go down with ease. Please.
What usually happens is that the metal laryngoscope shows the anaesthetist where the cords are and then the rubber tube is guided along the edge of the scope and passes between these cords. And then a balloon is inflated which sits just below them in an area called the subglottis and anchors the tube in place. And then the other end of the tube, the one outside the patient's mouth, is attached to the oxygen tube.
But this anaesthetist took the laryngoscope out and repositioned it several times. He did not reach sideways for his consultant to lightly whack the tube into the palm of his hand. He heaved a bit. His Asian face had a reddish tinge to it. After a short while, during which time I hardly dared draw breath, he shook his head at his boss and stepped aside to let his senior have a go. I looked down at my gloved hands so that I didn't seem too keen to ask the anaesthetic reg exactly what he had seen. I held these hands in front of me in the manner of someone approving recently manicured nails, a buxom diamond engagement ring. I saw little drops of moisture within the web spaces of my fingers, on the other side of the waxy rubber.
The consultant anaesthetist had now been attempting to gain access to Mr Charles's airway for about a minute. My consultant was minutely shifting his weight from one foot to another, so that I intermittently felt the warmth of his right shoulder against my left one. Just as it was beginning to look inevitable that we would be performing our slash trachy, the consultant reached sideways. He had to flap his hand impatiently – his eyes still trained on the laryngoscope – because his junior had given up on the idea of handing the equipment to him. The breathing tube changed hands like a baton and was carried over the finish line. The consultant then stood back with satisfaction and turned to his registrar to say, 'Bastard of an airway, mate. Nearly couldn't get it in myself.'
Then he turned to Mr Millard and said, 'Rip-roaring supraglottitis. I'll let ITU know he's ours for a bit.' My consultant nodded, dumped his mask and gown in the black theatre bin and, with a nod to me, was gone. I stayed to clear up with the anaesthetic reg and then went off to finish the ward round. Some of the patients were antsy by now. They had been told by the staff nurse that their doctor would be round about eight. It was now eleven. But I didn't care. My suit felt stylish on me now, the thick handle of my leather briefcase warm and snug in the palm of my hand. Even Daniel seemed bouncier and less awkward about pushing the trolley for me than he had before. Imperceptibly, I had arrived.
Good surgeons are decisive. They don't hover over the operative field. This ability takes a certain courage, and is often accompanied by excessive self-confidence, never stronger than in youth. Although I did the right thing to take my patient to theatre that day, there is truth in the surgical saying that 'A good surgeon knows how to cut. A really good surgeon knows how not to.' Maybe one of the most important reasons we all train for so long is to ensure the self-doubt that is a part of getting older. This awareness of one's own limits may prove more life-saving than any knife.