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My second year after qualifying as a doctor. It was early evening, and I was two hours into my shift at a busy casualty department of a district general hospital. We were the only neurosurgical unit for miles, and so took every stretcher case and blue light, from heart attacks to serious head injuries. The walking wounded came in through the hospital’s front doors, and more often than not complained about the length of time they had to wait before being seen. They had no idea what turmoil and drama lay behind the wall that separated them from the cubicles of the main casualty department. Much of the time we were overwhelmed by the sheer volume of ambulance cases brought in through our emergency doors; patients covered in foil to prevent hypothermia; the elderly strapped in wheelchairs and wrapped in blankets, with obvious signs of stroke; others in stretchers with collars around their necks and intravenous lines already in their veins, clothing soaked with blood and exposed fragments of bone.
The casualty department, especially in the evening and at night, was staffed by a team of very experienced nurses and often rather inexperienced doctors. The post felt an easy option and offered a breather from the relentless junior doctor ‘rite of passage’. Unlike other posts with 72–80 hour stretches and no protected rest periods, working in casualty required us to work in shifts: a week of days, a week of nights (9pm -9am) and a variable period of split shifts in between, which meant being on duty from nine to one and again from five to eleven the same day. When a ‘blue light’ was due the nurse in charge would allocate a number of staff to be on standby, often with a minute or two’s notice.
That night, a young woman was rushed into the department having suffered a heart attack. A team of us dashed into the resuscitation room and began cardiac massage until more senior staff were on hand to take charge. Access to a vein was paramount, as well as getting an airway into the windpipe. The defibrillator was always at hand. Given the patient’s age, we fought for much longer than usual to try to save her, but to no avail.
As the equipment and resuscitation paraphernalia were being put away, the anaesthetist encouraged us to have a go inserting the tube into the airway. It was a necessary part of clinical training, at a time when mannequins were not widely available, and often the only chance one had to learn and practice the skill was when a patient was being prepared for surgery. But it was often difficult to dissociate from trying to save a living person, only to end up practising a skill on a dead body.
We left the nurses to inform the relatives – they were often better at it. They seemed to have the time to spend with them; certainly they were not afraid to comfort them or to show emotion. Unfortunately, it also meant junior doctors never got a chance to learn and practice such skills. I also remember consultants I have worked for sitting with patients behind closed doors, or drawn curtains, breaking bad news about a particular diagnosis or terminal illness, but we were never involved. That night, the nurses had comforted the young woman’s sister, who turned out to be her twin. The department was in chaos, as she promptly developed all the acute symptoms her deceased twin sister had just an hour before.
Casualty is a strange place. It is the most acute end of clinical practice, and provides a wealth of experience as long as one is prepared for the gamut of emotions and the juxtaposition of the most trivial symptom with life-threatening conditions requiring immediate action. I enjoyed my six months immensely, and I have the deepest admiration for those who have made a career in this most challenging field of medicine. In those early years of my clinical practice I enjoyed watching the American television soap drama series ‘St Elsewhere’, about a group of newly-qualified doctors in a fictional underrated Boston hospital, St. Eligius, and their first year in hospital practice, disorientated by chronic sleep deprivation, constant bleeps and real-life dramas. It was known for its gritty, realistic drama and seemed to capture what it was really like for us at the time, yet it did so with such humour and gentleness. It was the precursor for many of the medical dramas we have on our television screens now, and portrayed the medical profession as admirable people with good intentions in serving their patients, but with their own personal and professional problems. There was a lot of black humour, inside jokes as well as real humanity. I remember thinking how the nation’s hospitals and casualty departments were run by people like me, so inexperienced and yet out there, in the front line. It was a sobering and rather scary reality.
Perhaps I am looking at my early clinical experiences through rose-coloured spectacles, but I can still feel the buzz of a busy casualty department. I can hear the drunken demands of disinhibited patients on a Friday night, the sirens of a blue light, the grumbles of the walking wounded tiring of the same television programmes being screened in the waiting room and the hushed whispers or anxious, aggressive behaviours of concerned and desperate relatives. There was such need out there – a constant demand for medical attention. Sometimes, those who shouted loudest were far healthier than the poor overworked doctors who eventually came to attend to them. We very rarely took days out sick. Hospitals rarely employed locum doctors to cover an absence unless it was for an extended period of planned leave, and even that was exceptional. It was not so much the guilt of being away from patients. Taking a day off meant leaving other medical colleagues, already heavily burdened, to deal with more.
One evening I was sagging under the weight of it all. My husband had urged me to go into work. ‘You’ll be all right,’ he said. ‘You’ll survive’.
I shouldn’t have to survive. I was coughing and spluttering; my head was throbbing, my body was feverish and achy, and it was difficult to concentrate on the task at hand. It was 10pm. I had just been told off by the surgical team for asking them to review a young man with a severe head injury, for a second opinion, because I should have known better and discharged him with a head injury warning card. I could hear the house officer as he left, criticizing and mumbling to the three medical students shadowing his ‘on call’ duties, saying how I was usually a reliable casualty officer, making only appropriate referrals. And the demands kept coming; nurses came up time and again to remind me to see cubicle number so and so, or someone required pain killers, or there was an X-ray to look at. My head spun round, and patient and staff voices became a kaleidoscope of noise around me. I felt so physically ill and at breaking point – and finally, I burst into tears.
Hoping no one had noticed, I took myself off into the sanctuary of an unoccupied minor surgery suite next door and sat for a few minutes regaining my composure. After all, I only had a few hours to go. My husband, who was working the opposite shift in Casualty, and I would only pass each other as ships in the night as we came on and off duty, not even having enough time to remind the other to buy a pint of milk. But it didn’t go unnoticed. There was a young staff nurse working that night who saw my distress and came in after me, to offer some comfort and solace. She didn’t stay long, but just knowing there was somebody else out there, in the department, on the same shift, who was in some small way keeping an eye on my well-being helped get me through the rest of the shift.
When I went back I was immediately involved in the aftermath of a severe road traffic accident. After a hefty dose of paracetamol and as many hours of daytime sleep as I could get, I was back on duty for my next stint twelve hours later.
My time in casualty holds many memories – many deaths, but many successes too. We often do not remember the latter, and the media are complicit in this biased selective memory. Headlines are full of disasters, malpractice and medical or hospital scandals. No one reads much about how well they have been treated in spite of the circumstances, or the hard work and dedication of doctors and nurses. Actually, the public do have a soft spot for nurses, mainly I think because patients see them more often, and understand what they do and the important role they play in the delivery of everyday care. They have less understanding of the stresses and working conditions doctors face. We get very little thanks, but we certainly know it if there are complaints.
I have particular memories of my time as a casualty officer in a busy accident and emergency department. In particular, I remember the numerous aortic aneurysms we saw come through the department; patients with such large pulsating masses in their abdomens that were in danger of rupturing at any moment. The multiple stroke victims, young overdoses, children distressed by whooping cough or distraught parents of children with febrile convulsions (fits due to a fever). As a neurosurgical unit, we saw a range of head injuries, from those who were mildly concussed to those who had been involved in serious road traffic accidents. But there were three clinical encounters that made a lasting impression on me, and steered my growing interest to specialize in mental health.
The first was an unkempt-looking man in his thirties, dressed in a striped pyjama top and sitting in a casualty trolley, waiting to be examined. I found out from the ambulance men that he was known to suffer from chronic schizophrenia, a severe mental illness in which the boundaries between fantasy and reality are fragmented. That evening he had put his music on full volume, which prompted the neighbours to call the police. He had then taken a chainsaw and cut off his penis. There was hardly any blood, and one of the policemen almost stepped on his dismembered part lying flaccid on the floor in the dark. When I examined him, he spoke not a word. He didn’t even look distressed, and was clearly in a catatonic stupor. Luckily, he had been found in time and the urologists were able to suture his penis back on in an emergency operation that night. I never knew what happened to him, although I assume he was transferred into psychiatric care when his physical health allowed.
The second involved a young nurse who was resident in the hospital campus. She had been found by her friends crawling along the corridors of the nurses’ home, completely naked, talking about strange happenings in her bedroom. She spoke of objects moving on the shelf of their own accord, and other visual hallucinations. I was able to persuade her to go into the local psychiatric hospital for a brief admission, but again have no idea what actually happened to her. However, my management of her presentation in the casualty department as a fairly inexperienced doctor must have got me through my interview a few months later, when I applied for my first psychiatric training post, as they were impressed that I had found out she had been diagnosed with an acute drug-induced psychosis.
Substance misuse played a significant part in the third case I remember well. I saw this patient in casualty when I was a surgical houseman. It was my first job after qualifying, and it was scary – especially being ‘on take’. It was an absurd situation really. Casualty officers at least one year my senior would be making referrals to me as the surgeon on call. I would trot down to the casualty department after a day assisting my consultant in the operating theatre to assess a new patient and decide whether or not to admit them into hospital, or indeed whether emergency surgery was warranted. One day, in the early hours of the morning, I was bleeped to see a young man who had been brought in by ambulance and accompanied by the police. The casualty officer suggested I called my more senior colleague on duty with me to see him too, so I knew something more serious than appendicitis or a perforated ulcer was waiting for me. The patient was a young man who had been sniffing glue with some friends. Together they had broken into a local warehouse, setting off the intruder alarm. With the police hot on their trail, the individuals involved jumped through an open window to the street below in an attempt to escape. They were all caught, but this patient was not so lucky. He had jumped out of the window, only to impale himself on the spikes of an iron railing below. The wounds in his abdomen and thigh looked quite innocuous – small and hardly bleeding at all – but when we took him into the operating theatre, we were there for hours suturing each laceration.
Our boss was away for a few weeks, and we had a locum consultant surgeon take charge. He was a tall, brusque man with an engaging grin and an athletic stature. He seemed approachable enough, and certainly did not mind being called into the hospital from his warm bed in the wee hours of a cold winter’s night. But something changed when he got into his surgical greens and scrubbed up with a mask over his face. He insisted on operatic music being blasted into the theatre as he worked, he threw blood-soaked cotton swabs at the nursing staff and was generally abusive to everyone in sight. I couldn’t believe the complete change in his demeanour; it reminded me of drivers behind a steering wheel. In the relative safety of their own vehicles, the most placid of people can become aggressive, careless and quite dangerous.
The young patient stayed long enough for his wounds to heal, and discharged himself from the hospital prematurely. I am not sure if the police ever caught up with him.
Fourteen years after first setting foot at The London Hospital as a naïve overseas medical student, I walked out of Whitechapel underground station and took in the East End air. The street stalls were being set up for another day. Not much had changed around me, but it felt so different. I remembered the first patient I had encountered in my training; I was prepped with a checklist of questions in my head and went to take a medical history from her. She told me she had something wrong with her ticker. I didn’t know what she was talking about. This wasn’t the English language I had learnt at school. I used to bump into her often after that, at the station, as she attended for her various appointments. She always asked how my studies were going. Now the façade of the old hospital building, once such a foreboding and inspiring sight, gleamed in the early morning sunshine and beckoned my return. I had been appointed as a consultant psychiatrist, to the teaching hospital in which I had trained, a hospital that had been founded almost 250 years earlier. It was the first medical school in England connected to a hospital, and I was going to work amongst colleagues who were formerly my teachers. I was very conscious of the psychiatric department’s international reputation and its eminent professors. They were leaders in the treatment of psychosexual disorders, bereavement, loss, abnormal grief reactions and psychiatric aspects of epilepsy. The department had a strong and passionate workforce of dedicated academics, researchers and clinicians. It marked a dynamic and promising start to my consultant career.