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I have been fortunate in my life to have met so many good role-models and mentors who have shown me the way through their counsel and example, and given me such wonderful opportunities to learn. It is a never-ending process of education and reflection and personal development. Many of my patients have been through indescribable emotional, psychological and physical traumas, yet they have a humility about them and the human strength to continue to laugh and love. They have been the source of my real development as a clinician. It is not something taught from text books, or in the classroom.
One tragic case I remember from my first job as a surgical houseman was a man in his forties who had an oesophageal cancer. He could not afford to wait for his operation on the NHS, and decided to have it done under a private health insurance. I clerked him in; I chatted with him, took his medical and social history and gave him the required examinations and blood tests before his operation. Despite the gravity of his condition, he was relaxed and cheerful and spoke with such a sense of purpose and inner calm. He showed positive optimism as he took control of his life and decisions. He had a young family, and wanted to get the operation over and done with so he could spend as much time as he could with them. I knew he was in good hands – the very best. My consultant was an experienced and dedicated man, with such a good surgical technique that there was hardly ever any blood in his operations. None of the gory scenes one normally associates with surgery. His work was neat, meticulous and sound. He was an expert in his field, a highly-regarded tutor, and had an unusually good bedside manner – for a surgeon. His training job was the most sought after amongst newly-qualified doctors and more senior trainees alike, and I was lucky enough to have landed it.
It was a private operating list, performed separately from his NHS work. I was asked to assist him in the four-hour long operation, as he opened the patient’s abdomen and proceeded to pull the stomach up through the chest cavity after he had resected the cancerous part away. His surgical glove was covered in blood, right up to his elbow, but the operation seemed to go well and afterwards he went to speak to the man’s wife.
That night, whilst in intensive care, the man started to bleed from his internal wounds. My consultant came back into the hospital, and again the same surgical team went to work to stop the bleeding. The tissue was so friable it had burst apart at the sutures and almost the whole procedure had to be done again. I was exhausted, but adrenaline kept me going. I was rooting for this man; he just had to make it.
The following afternoon, we had to take him back to theatre again – and this time, he died on the operating table. I was shocked by the whole experience. I felt for his wife. I felt for his family. He didn’t deserve to die. The irony was he had paid for the operation outside the NHS; the operation that killed him. In the months that followed his surgical bill was settled. I was given a nominal amount for my assistance, but it felt so wrong to take it.
In those days there were moral dilemmas and clinical decisions we were expected to take as junior doctors, without involvement or advice from others. Thankfully it doesn’t, or shouldn’t, happen now but looking back at the diaries I have kept over the years I found this entry from 1984. I had been in clinical practice for 7 months.
He came to us through A&E
A query MI at seventy-three
‘Look at those changes on his ECG,
He’s had a massive coronary.’
The vice-like pain across his chest
Went down his left arm,
For ten minutes he lay in agony
Before he raised the alarm.
Breathless, sweating and with irregular beats
He called out his wife’s name,
She reached out for his angina pills
But the pain was still the same.
He came to us through A&E
A query MI at seventy-three
‘Look at those changes on his ECG,
He’s had a massive coronary.’
In haste we slapped leads on his chest
And wired him to the screen,
Whilst another got venous access
And administered diamorphine.
His pupils constricted, his pain eased
His pulse a regular seventy-three.
His BP dropped to half his norm,
But he remained symptom free.
I spoke to his wife explaining his state,
And painted a picture of gloom,
She sat and listened, smiled and laughed
As though not in the same room.
He came to us through A&E
A query MI at seventy-three
‘Look at those changes on his ECG,
He’s had a massive coronary.’
Before him lies the critical time
These seventy-two hours ahead,
His rhythm is good but his heart’s not strong,
We’re monitoring him in bed.
Into cardiogenic shock he went that night
His blood pressure continued to fall.
We set up a dobutamine drip
It didn’t pick up at all.
I spoke to his wife again the next day
She seemed not to hear.
Then suddenly I was called away;
I knew his end was near.
His breathing laboured, his eyes glazed
He was sweaty, really quite blue.
Should I resuscitate this man?
My judgement was torn in two.
I knew it would be to no avail,
Yet could I deny one last try?
‘Doctor, should we put out the arrest call?’
I stopped… In peace I would let him die.
So instead of the panic and heroic deeds,
I let his life slip away.
His wife sat with him till the end.
I think… I would make that choice again.
Inadvertent deaths caused by overdoses was another aspect of my clinical work I found difficult. My first encounter was during my medical house job, the year after qualifying. Those years as a junior doctor are something of a hazy memory, as we all struggled to cope with the physical and emotional demands of our workload. Thirty-two hour shifts during the week with 80 hour shifts to cover a weekend, no protected rest periods and a pittance of a salary which was often misquoted by the media when they fought for nurses’ and teachers’ pay. Working outside the Monday to Friday 9-5 resulted in payments for units of medical time (UMTs). Rather than attracting a premium, it was paid at less than a third of the normal rate. The National Health Service in England was a monopoly employer and this allowed hospitals to exploit the working conditions of junior doctors who needed to be in accredited training posts. However, such long hours, with no protected breaks and little opportunity to get proper food, were considered a rite of passage, allowing us to gain invaluable hands-on experience in clinical practice and autonomous decision making. Such intense conditions engendered a deep sense of camaraderie, and the knowledge of working together as medical or surgical teams with ward staff gave a real sense of collective responsibility and continuity in the delivery of clinical care. We wouldn’t let our colleagues down, even if we felt ill ourselves.
Although in the early days of my training hospitals still had a doctors’ dining area, complete with tablecloths, this soon disappeared. On call, we were lucky if we managed to get a sandwich or chocolate bar from a vending machine, as the canteen would invariably be closed. In my early years after qualifying, the doctors’ mess and the doctors’ bar allowed some relaxation, and alcohol could be bought and consumed when on duty. Both have disappeared. The on-call room, with its single bed, basin and telephone, was barely used. Sometimes it would be a sparsely-furnished room in the nurses’ home, far from the hospital wards and casualty department; on one occasion it was at the other end of the hospital grounds beside the mortuary.
Certifying a death was one of the duties of the junior doctor. The call often came in the early hours of the morning. In the beginning I would respond as quickly as I could to the nurses’ request to come onto the ward when a patient passed away where a decision had been made earlier not to call out the resuscitation team in the event of a cardiac arrest. We had to check for and certify the absence of vital signs of life and note time of death. But after being so shaken by agonal (death) breaths on one occasion in the first few months as a junior, I made a point of waiting for a while before doing so.
Perhaps the chronic tiredness we felt was inbuilt as a means of detaching from the traumas we faced in everyday clinical practice. Rarely did we have the time to think about our patients as people as we coped with life-threatening conditions and overwhelming experiences. Weekends when we were not on call were spent getting away from it all; a good friend often invited me round to her little attic flat on the edge of Hampstead Heath. Before singing with her choir at Evensong we would walk her dog on the heath, enjoying the restorative beauty of the natural world around us, and talk. I remember confiding in her about how difficult and conflicted the practice of medicine could be; how I tried my best to not let patients, especially dying patients, feel alone and to endeavour to keep them pain free, sometimes knowing the levels of painkillers prescribed might lead to an earlier death. Such young people were dying of cancer, while others who were unable to look after themselves somehow managed to survive the most horrendous operations.
‘Well, maybe they’ve done what they came here to do,’ she suggested. It was so simple, so full of faith, that I felt very comforted. She became my dearest and closest friend.
One weekend, when I had taken over from the previous on-call junior doctor, I was doing my obligatory round of all the medical wards, checking to see if things needed to be seen to in order to avoid any trivial calls later in the day. Tasks like re-siting drips that had tissued, writing up medication for patients to take home as they prepared for discharge; checking through the mountain of blood test results which flowed onto the ward each day; writing up fluid charts, checking in with the nursing station and just being visible on the wards so patients knew a doctor was about in case they needed one.
I stopped by the end of a hospital bed. An Asian family were sitting around, engaged in jovial conversation, whilst a young teenage girl was lying in bed, oblivious to the goings-on around her. I had made a particular point of visiting her, as her treating clinical team had said she was suspected of having taken a large overdose of paracetamol tablets after an argument at home. They had advised that it had been too late to give her an antidote by the time she presented to them. When they assessed her she clearly had no wish to die, but had taken the tablets out of frustration and desperation to escape her situation. She had no awareness of how dangerous her actions had been. I greeted the family with a nodding smile and went to review the observation charts at the end of her bed. The nurses on the ward had taken regular recordings of her temperature, blood pressure and pulse. The last entry read: Pulse = 0, BP = unobtainable. I looked at the pretty teenager lying in the bed in front of me, so still and quiet, and had no choice but to draw the curtains and put out a call for the crash team.
I felt so angry at being put in such a position, and guilty that had I checked on her earlier in the day perhaps her fate, or at least what the family witnessed and experienced, could have been avoided. There were so many ‘whys’ and ‘what ifs’. Why hadn’t the nurse called the crash team when she couldn’t obtain a pulse and blood pressure? Why hadn’t the girl or her family sought help sooner after she had taken the overdose? I remember her coroner’s inquest, but I don’t know what happened to the nurse involved.
On another occasion, as a young psychiatric trainee, I was summoned to attend a coroner’s inquest. By then the consultant who was in charge of the case had emigrated to another country, and left his junior staff team to account for the decisions made. Six months after the suicide, the three of us met again for the first time outside the court room, having previously gone our separate ways when our six-month placement had finished. It was strange meeting; I was glad to have the company of colleagues who had been with me at the time of the ordeal. In the weeks leading up to the inquest, I had met with experts from the medical defence unions, gone through my statement with them and considered whether or not there were any grounds for malpractice on my part. Thankfully there were none, and I felt at least confidence that should the inquest proceedings take a nasty turn, legal representation would be made on my behalf. The hospital was not there to support us as they often are these days.
The deceased was a young mother. We had admitted her into the mother-and-baby unit at her local district general hospital. She had been suffering from post-natal depression and had suicidal thoughts but was otherwise relating fairly well to her new baby. There were no homicidal thoughts she admitted to, and she was able to look after the infant with some prompting and support from staff on the ward. Placid by nature, the baby quite happily slept in his cot beside his mother’s bed whilst she joined in with ward activities, group therapy and individual work. She was an articulate woman, gentle, easy to talk to and eager to understand her illness. I visited her daily on the ward, reviewing her mental state, depression and suicidality. I liked her husband too: a tall, lanky man with a full beard. He looked like an artist, and I could imagine the creative and intelligent upbringing the little boy had in front of him. They were a devoted couple and supportive of one another. I felt a sense of relief that the baby did not need to be removed from his mother during her illness, and that mother and baby were able to bond with each other in spite of everything.
She made good progress on the ward over the weeks of her inpatient admission, and was looking forward to a brief period of leave over a weekend. Before I left on my annual leave, as we had to take two and a half weeks in each six-month placement, I had a ward round with my consultant. He was a young, up-and-coming academic psychiatrist who seemed more interested in getting his name in print than he was in clinical practice. He had a detached manner about him, and his harsh, croaky voice did not fit well into his short, slim frame. The stubble of a moustache only accentuated this awkwardness. The clinical team did not know him well, as he was appointed to fill in for a more senior consultant who had taken a year’s sabbatical overseas.
It was during this ward round, when we had finished discussing all the patients admitted under his care, that he told me the ward was due to be refurbished and the psychiatric liaison ward would be dismantled. Patients were to be dispersed around the hospital, in general medical wards, or discharged home. There would be no mother and baby facility on site for the foreseeable future. I was dismayed for our patients. Whilst some could be transferred to the large psychiatric institution a few miles away, it was difficult to see how those with additional medical problems could leave the general hospital. I advocated for this mother to be given a large side room at the general hospital, as I knew she was not ready for discharge and admission into the psychiatric unit, which was unable to admit her baby with her, would be detrimental.
On returning from leave I found that a small number of patients had indeed been dispersed around the hospital, but she was not amongst them. She had been discharged after one successful visit home, and would be returning to receive outpatient treatment instead. A few days later we were informed that she had died, having hanged herself in the family kitchen.
My heart went out to her husband, sitting there in the coroner’s court. He blamed everyone who had treated his wife, but most of all he blamed me – and I could not understand why. We had developed a good working relationship; he had been kept fully informed and consulted at every stage of his wife’s treatment; he seemed genuinely to appreciate all the support she had been receiving. Perhaps it was because I had gone away. Accusations flew in the heat of the inquest and stung me, but I knew I had not done anything wrong. If only I could have spoken with him one to one, if only my consultant had been there to answer the questions leading up to her discharge from hospital – if only, if only.
The Old Bailey, London’s Central Criminal Court, first mentioned in its medieval form in 1585, strikes an intimidating chord in the heart of any non-forensic practitioner called upon to give expert witness. After all, hangings were a public spectacle in the street outside until 1868. It was early in my consultant career, and I had appeared in various courts before, at coroners’ inquests, child care proceedings and magistrates’ courts, but never at the most famous of them all.
Built on the site of London’s old Newgate prison, one of its most famous trials was that of the Yorkshire Ripper. On the dome above the court stands a bronze statue of Lady Justice, holding a sword in her right hand and the scales of justice in her left. For some reason I expected a grand entrance, with a massive courtroom and lots of reporters outside its imposing edifice. There is the Great Hall decorated with many busts and statues of British monarchs, legal figures and others who were renowned for campaigning for improvement in prison conditions in the eighteenth and nineteenth centuries. Perhaps I was too close to it all, because my clearest memory was the narrowness of the entrance I had to go through. There was a queue of people waiting to get into the gallery to view the court proceedings, and there was another much faster-moving queue for those like myself who had business there. Dressed in my one smart suit, which only made an appearance at interviews and formal business occasions, I stood in the little lift as its doors closed, wondering what was in store for me that day.
The trial was to assess a defendant’s fitness to plead. I had been called as an expert witness, to give evidence about a young man with learning disabilities who came from my practice area. He had been accused of abducting young children, and the courts wished to consider whether or not he was fit to plead and stand trial. If he were found fit to do so, he would go through the full criminal justice system. However, if he was deemed not fit to plead, the court would send him to a long-stay secure mental health facility for treatment. Although he was not known to the learning disability or psychiatric services, I had been approached to examine him and prepare a report as well as attend the court proceedings. When I had interviewed him in his prison cell a few weeks earlier I had been given access to all the statements relating to his offence. He had approached young boys on the pretence of being a policeman, and invited them back into the flat he shared with his mother and her partner. On the first occasion a few years earlier, the boy had stayed the whole day but was accompanied home when he began to feel afraid. The prisoner was given a probation period. However, on this occasion in question, he had kept the boy locked in a cupboard without food or drink, causing much distress to him and his relatives.
When I met him in the interview room at Brixton Prison, he was agitated and suspicious. He spoke about the persecutory voices he was hearing around him, super powers and visions of a tall woman talking to him. He claimed to have drunk a bottle of bleach and to have engaged in suicidal behaviours such as tying bed sheets together in an attempt to hang himself, and using an old razor blade on his wrists. However, none of these incidents were discovered, much less documented in his records. He denied the offence, and said he was in prison so that he could be kept out of harm’s way. However, I noted his string of minor criminal offences, his long contact with probation services since his early teenage years and his superficial verbal ability.
It was difficult to assess whether his mental state was the result of imprisonment on remand, and the pressures of an impending court appearance, or whether he had been suffering from a psychotic illness before his arrest. He appeared unable to follow what I was saying and spent much of the time fearful of what the telephone or the panic button might do to him. The relationship between us in that sort of setting was obviously not a confidential one; perhaps that played a part in what he was prepared to disclose. Clearly he had intellectual impairment, had played truant from special schools and been physically and emotionally abused as a child. His alcoholic father had often locked him up; his mother appeared to have learning disabilities of her own. He was clearly vulnerable and had been easily led into a life of crime and exploited by others more able than himself.
He played down the offence when challenged, explaining he had only wanted a companion and adamantly denying any paedophilic tendencies. Gaunt and shifty, the bearded young man sitting in the dock looked a completely different man from the one I interviewed a few weeks earlier. He seemed more confident in his manner, alert to his environment and well presented. Taking the witness stand, with the gallery full of people, and the judge and barristers in their wigs, I had to remind myself to breathe and speak slowly. I knew I had to concentrate on the question asked, and answer only the question asked. I focused my mind on the judge sitting to my right.
The problem with a psychiatric assessment is that one tends to rely heavily on a patient’s self-report of symptoms. Assessing someone with learning disabilities can pose considerable challenges, not only because of their limited language skills and hence their ability to understand what is being asked, but their limited ability to name an emotion or express themselves verbally. To add to this complexity, there may be perceptual and sequencing difficulties, so that they are unable to give information in a correct temporal sequence, missing out huge chunks of detail and giving unconnected narratives. There may be additional short-term memory problems, difficulties concentrating, sensory impairments and social skills deficits. To make the situation more difficult, people with learning disabilities respond to the perceived power and status imbalance that exists between themselves and the person they are talking to. In such situations, they are more likely to acquiesce and respond and say what they think is expected of them.
He was found fit to plead and eventually a separate trial went ahead and he was convicted. The judge was not inclined to give a non-custodial sentence, preferring instead to sentence him to an indefinite period of specialist care and rehabilitation at a secure hospital. At this stage, my services were called upon again, as I was the only consultant psychiatrist working in the field of learning disabilities, responsible for the London borough from which he came. However, inpatient facilities were, and still are, an extremely scarce resource, and I was unable to put together a secure package of care in the time frame stipulated by the Court.
There was uproar. The judge threatened to call for the Secretary of State for Health to take the stand to explain why such services were not available. The civil service cogwheels moved as I have never seen them move before. I had a phone call from the Chief Medical Officer – the highest doctor in the land, so to speak – enquiring about the situation. He was sympathetic to the difficulties, and volunteered to help secure an appropriate hospital placement. Before I knew it, a bed had been found for the convicted prisoner’s transfer, to a specialist hospital outside of London. I knew it meant that someone else had either been denied the bed or transferred out prematurely. A few months later, the prisoner was moved yet again, into a high security hospital, as his dangerous and psychopathic tendencies became more apparent.