Perhaps the most exciting six months in any junior doctor's training are those spent in A&E. Nothing is gentle there. Catastrophes abound, the diseases are dire, the episodes of human dislocation momentous. But what struck me most about this department during my first few days working there was that all visitors to A&E seemed to be coming there to lose something. Some were losing a loved one, some their own life. There were suicide attempts by people who had lost faith. There were incidents that caused loss of limb. There were unforeseen events that caused loss of function or loss of beauty. There were illnesses that were severe enough to result in loss of personality. I came to see A&E as a sort of departure lounge in which every patient had come to say goodbye to someone or something, often with no warning, usually with no time or peace or preparation.
Within this pageant of loss, I remember the quiet case of Cheyenne. Her casualty card, picked from the top of a stack which never dwindled, said bleeding per vaginum, cubicle three. I found her looking forlorn in this six foot by four foot space, which was separated from the menagerie of the rest of the department only by some thin partitioning and a curtain. She wore a hospital gown, which had the name of the hospital written across it diagonally in a small font over and over again, alternately in yellow and brown, like punishment lines from school. She was wearing a lot of make-up and I thought how old I was compared to her. Her hair was a bad blonde and she had big hoop earrings in her ears, but she had obviously given up on her efforts at foot level, because they were grimy and her toenails uncut and grey.
I said a matey sort of 'Hi', hoping this would put me on her level. Then I collected some blood by putting a cannula in a vein in her arm, in case she needed a transfusion. I connected a drip to this same tube and started up some IV fluids. Finally, I settled down to hear her story.
My patient was sixteen years old and twelve weeks pregnant. The pregnancy had been unplanned but was not unwelcome, except for Cheyenne's mother who was so angry that she had thrown her daughter out of the house. Cheyenne had been staying with her boyfriend's parents for the past few weeks. The bleeding had started that afternoon during her shift at the supermarket. In the past hour she had changed her sanitary towel five times.
She was alone as she told me her story. She said her boyfriend was going to come when he finished work. She was calm to begin with, but soon became uncomfortable and then complained of severe pelvic pain. I told her I needed to have a look. I put on my gloves and tried to shield the tray of instruments I had brought in with me with my body. I unwrapped the gynae pack from the green sterile paper which made it looked like a merry present. Everything inside the metal tray appeared unkind, and at its base was a platform with holes in it so that any blood could trickle through it and collect below and not swamp the useful tools.
She lay back and I positioned the anglepoise lamp, which was attached to the wall, so that its wedge of light entered her. She had let her knees fall apart with her feet still together without my direction, and something about this made me feel sad. I pushed an inco-pad, like a baby's disposable changing-mat, under the W of her bottom. At first, all I could see was blood flowing from her. I was near enough that I could see the tiny particles in it moving out and onto the white pad.
Telling this stoical bleeding girl what I was doing, I put a shiny bullet-shaped metal speculum inside her vagina and spun its metal screw so that the two curved sides of it winched her open. Blood was pouring from her and I decided that if things went on like this for much longer, I would have to move her round to Resus, where you put people if you think they might die. But I had something to do first, that I hoped would help.
What I wanted to check was her os. This is the mouth of the cervix. The door which leads from the accessible vagina into the less accessible uterus. When someone is having a miscarriage, this can get held open by a clot of blood which in turn causes extra bleeding and pain. I had been taught that clearing the os can improve things.
Cheyenne's whole body was shaking and she was crying. Directing the light further inside her, I could see that the os was indeed being held open by a piece of tissue, a bit of what is medically known by that coldest of words, 'product'. I reached for the longest set of forceps in the pack. I regretted the steely clattering noise I made as I dislodged this instrument from the other things that lay there. These forceps sit in your thumb and finger like scissors. And then the long arms curve out and then back together in two little circles which meet in a clasp.
I told Cheyenne that I was going to try and stop her pain and her bleeding and I reached inside her. I apposed thumb and fingers so that the forceps came together in a decent grasp around the stuff that was sticking out of her womb. I pulled, expecting this clump to come away and for the os to close. Instead, Cheyenne made a pushing noise and an action to go with it, and a dark mass the size of a grapefruit emerged from her os, travelled the short length of her vagina and emptied itself on the inco-pad.
I was aghast. I felt sick and alarmed and didn't know what to do. Cheyenne's head was thrown back with physical relief and I was glad that she couldn't see my face, which would not have looked good. I glanced down. In the pool of blood that was making an ever bigger circle in the quilted white pad, I saw the shape of a baby. Head, arms, legs, back. All curled up.
Automatically, I folded the top of the inco-pad softly over this mass and, still holding the bloody tongs, I stepped back the two paces it took me to get to the curtain. I didn't want to turn my back on Cheyenne's face, because I didn't want her to see what I had seen. I put my head round the curtain, tucking its rough material under my chin, so that just my face poked out. I really wanted a nurse. Two of my doctor friends were writing notes at the central station a metre or so from where I stood. I remember thinking how strange A&E was, with its distinct bloody universes, all rammed up next to each other. One of them looked alarmed at the sight of me and said, 'What do you need?' 'Nurse,' I said, and pulled my head back inside.
In the few seconds that my eyes had left Cheyenne, she had sat forwards. Her legs were still apart, as before. She had folded back the leaf of the inco-pad. There was blood everywhere, but she seemed not to notice or mind. Her face was dry and looked unbelievably sweet. With one finger she was touching the gory mass in front of her ever so gently and she turned her young glance to me and said, 'My baby.'
Then a nurse arrived with a tray into which she carefully lifted the inco-pad with its contents. Behind her was the duty gynaecologist, whom one of my colleagues must have called on my behalf. He said, 'I'll take over from here.' And then Cheyenne's boyfriend was there, and their teenage faces disappeared within their closed hug, and I knew that the opportunity for me to say anything meaningful to her had passed. I left the cubicle, to change my scrubs, to see the next patient. I have always wondered how those remains were disposed of.
Ten to fifteen such dramas played themselves out in the average twelve-hour shift in A&E. But however constant the flow of work, these desperate cases seemed unconnected. People either went home, or died, or were taken off to another area in the hospital to receive definitive care under other doctors, who would come to understand how the first shocking event that had brought them into the department fitted into some wider context.
For me, these patients seemed assorted into the random packages of my days, of cycle rides taking me to and from work, of changes out of dirty scrubs and into clean ones. I began to feel demoralised. Emptied. Cast down by all the loss and the viciousness. The drunken horrors, the strip-lit awfulness of life gone wrong. And all of this was playing itself out against the blankening canvas of my own life.
As doctors, the shift system of A&E had wrenched us from normal daily patterns, making any life outside of medicine hard. Our weekends and evenings were rarely our own; our days off tended to happen when everyone else we knew was at work. We shared amongst ourselves this sense of suspension in our lives. Relationships with people outside work fell apart and were replaced by new temporary ones within our close group.
Dislocation seemed all around, including on a much more significant, world scale. In New York, the twin towers were attacked and in the relatively unimportant locus of our A&E, we observed a unique phenomenon in the department's history: all the patients went home. We doctors sat in the empty waiting room watching the events unfold on television, in London's busiest emergency unit, nobody for us to treat.
Perhaps all of this gave rise to a need to recast the scene into something more optimistic. Because around halfway through my time in A&E, I stopped noticing all the loss and the doom. I started to pay more attention to whatever I could find amongst the chaos that might redeem it. I began to notice frills of kindness in the violent scenes, shreds of goodness that persisted through the bad. The modestly successful outcomes that laced the tide of hopeless ones. I forcibly observed, amongst all the disaster, a human heart drive towards some sort of community, to reconciliation, to harbour.
In what had previously seemed an inchoate workaday life, patterns emerged. There were patterns of clinical presentation, cases that echoed other cases, already seen. The fractured neck of femur in an old lady, the young man with ureteric colic. The rectal bleeds and bloody drunks. The feverish kids and rude grown-ups. There was also the constant of my own role in the department, although this was perhaps only tenuously reassuring. I remember asking one of the most experienced A&E nurses one day, with a sorry tone in my voice, 'Am I going to get called a cunt every single day in this job?' To which she replied, 'Just be grateful you're not being called a fat cunt.'
As a group of doctors, we had also formed a close group by this stage, with the usual characters and kinship dynamics. And just as the department provided us with a sense of community, so I noticed that A&E was home to many of the local unemployed. The waiting room was comfortable, with a new carpet, comfy chairs and a plasma screen TV. Every day, a group of men would congregate there, posing as patients, especially if there was some major sporting event on TV. They found the best seats and tucked their beer-packed holdalls under them. I even saw someone nipping into majors one evening at exactly the right time for the catering trolley, and returning to his station in front of the telly, hot meal on lap, and can of beer soldiered behind the leg of his chair.
These guys had a sense of belonging there; it was their spot. I saw them every evening that I arrived in or left the hospital. I'd push my bicycle through the waiting room and there they'd be. One evening, I was doing just this, going home helmet and anorak already on. Day-Glo stripes at ankle and chest. Suddenly, one of the punters had blocked me by standing in front of my bike. He had the front wheel trapped between his legs and the handlebars in his hands and he faced me, so that I saw the pores in his face, and said, 'Where do you think you're going, Doctor?' I don't think he meant this as a joke. Perhaps it was just too much to contemplate that any of us had somewhere else to go.
Mostly, though, I noticed a desire or drive for community within the patients' individual cases. In my mind's eye, I see a row of A&E cubicles like rooms in a doll's house in which good and order strained against disaster and accident. Knife-attack boys who came in having slashed each other, but left as friends. Deliberate selfharmers who came for regular conversation, as well as to have their cuts sutured. Families realising they loved each other, if only briefly, when death came knocking. And other, more mixed images like these.
I was sitting at the central station writing notes on a patient. I was near the CCTV screen, which showed what was going on inside the locked psychiatric room, a place with a proper door set aside for any patient deemed to be in a hazardous phase of a mental illness. I could see a black woman crouching in one corner at the bottom lefthand side of the TV. She was in the position of someone about to do a dive-bomb into a swimming pool, arms clasped round scrunched knees, head on arms.
I couldn't see John, my doctor friend, who was also in the room trying to find out why she had been found balled up like this in a supermarket aisle, refusing to speak or move. But I could hear his Northern voice talking to her, trying to coax something out of her. I was looking by turns down at my notes, up from my notes, sideways to the black-and-white TV screen when I was trying to fix a thought, down to my notes to write. Then the woman bounded up and I saw the back of John's head enter the screen like a big blur in the foreground. He had taken a step forward and his arms were held out slightly. Whether from a startled reflex of self-protection or in a desire to comfort, I couldn't tell.
The next thing was that she was pulling off her jumper. Then awkwardly pulling off her trousers, which were tight around the ankles and caught on her shoes so that she had to use one hand to support herself against the wall. I could see the dangling middle part of her wobbling with the effort of pulling at her shoes to get them off so that the trousers could follow. After this little undressing hitch, it was no time before all her clothes were off. And then there was a naked woman on the screen advancing into the camera view although of course not approaching the camera so much as approaching the space where I knew John stood. I could hear her voice now in little gravelly bursts, masculine almost in its urgency, saying first quietly, 'Fuck me,' over and over again, and then more loudly, and emphasising the pronoun of her lost self, 'Fuck me, Doctor, fuck me, fuck me, fuck me!'
The part of John's head that had briefly entered my view was not visible now, and I guessed he had taken a step back again, and perhaps was doing his best to press himself into the unyielding wall behind him. I started at the feel of breath behind me, and turned to see one of the male nurses reaching under my legs to get a blue hospital blanket out of a cupboard there. He crossed to the psych room and left the real world in front of me, to reappear a second later in the black-and-white hinterland of the TV screen, where he advanced certainly on the disintegrating woman, whose most basic urge, whatever her loss, was for company, for human communion, for expiation of disaster in the warmth of someone's arms. The rough blanket was soft about her and the door opened again to let John escape.
The persistence of human need for human, I also witnessed in the first assault victim I ever saw. I remember the cubicle I treated her in. This A&E department owned a funny old medical light, which looked like the kind of apparatus you might find on a film set. It was an upright structure with a big black tilting sunflower head that could be turned this way or that to cast its humming glare on any situation warranting white scrutiny. The way this vast head moved was disconcertingly human, a graceful face on a toned neck.
Someone had put this light in the cubicle with the patient I was about to see, perhaps to make up for the fact that it was one of those budget cubicles with no bed in it. When I went in, I was struck by the oddness of seeing a young woman sitting on a stool, and the nosy black light trained on her face. Its shine struck her so brightly that I couldn't even see the colour of her hair, which glowed spun silver, or her skin. And her pose was so still. But what I could see in this silent still-life glare – which she somehow couldn't resist the drama of, because her posture was light and straight and she was allowing the gaze of this light to dote on her uninterrupted and with no coyness – what I could see brightly was the imprint of a shoe across her face. That someone had stamped on her face.
I don't know how something that had made such a mark could have left the underlying face so relatively unharmed. This lady did not seem distressed and was not interested in conversation. She was monosyllabic. She did not want to tell the story, which emerged despite her, which was that she had annoyed her boyfriend so he had pushed her over and stamped his boot on her face.
I have a triptych of impressions from this. The way she looked when I found her. The feeling of cleaning her face with sterile swabs to make sure the grit from the shoe wasn't on it. As I did this, I was looking at the tread marks on her face. I was marvelling at their distinct neatness. As I drew a swab across them, I could feel the way the swab recognised the dints of the depressed treads against the raised untouched interstices. For some reason, it made my head full of that noise that you hear when you drive over a cattle grid. Sort of takatakataka.
Then my third snapshot is of when her boyfriend arrived and tears of relief filled her eyes and they embraced. His pose was that of the generous indulger, whereas she was demure. And he was saying, 'Sorry, babe, sorry.' And she was saying, 'I'm sorry too,' and it seemed a joke between them that I offered her social services support. A joke which they found so funny that they were still laughing about it even as they left the department together, holding hands back into their life.
These two women, the psychiatric patient and the assault victim, are hardly romantic heroines. And truthfully, their impulses towards human comfort might seem pathetic. I wonder now whether my insistence on noticing such things during my stint in A&E had more to do with my need to see things in a way that allowed me to keep doing my job, than anything particularly heart-warming about what I experienced of human nature in that most extreme of environments, the emergency department.