I have seen junior doctors bullied by consultants. I have seem them intimidated and persecuted, humiliated on ward rounds in front of patients and nurses, deliberately made to look stupid. Some consultants give nothing but kindness and support, while others seem to go out of their way to make their junior’s life a misery. Student nurses are more protected on the wards and they’re much safer because they have so many different colleagues they can talk to. Junior doctors are often on their own. We try to take them under our wing, but there is only so much you can do. I often think about the ones I’ve known – the good ones – and hope wherever they are, they feel valued. Everyone should feel valued.
The ward sister
The night shift began just as the others had done.
A handover in the little room with the plastic skeleton. The same doctor with the tired eyes. Claire, the Irish nurse. The exchange of bleeps and the passing on of jobs. My registrar never came to handover, but he was out there somewhere should I need him, moving around the hospital – dealing with the emergencies and making the difficult decisions, while I got on with the routine and the mundane.
There were only a few jobs given to me, and none of them was urgent, so I sat for a few minutes and looked through a list at the patients I wanted to revisit, people I’d seen on previous nights and wanted to check on. A man with a grumbling high temperature on the male surgical ward. A woman on the second floor with a urine infection we couldn’t seem to shift. A dying woman in a side room on Ward 11, who had managed to hold on to another day and still remained on the list. I put the piece of paper in my pocket and made a start.
It was just coming up to 2 a.m.
Everything was going well. I’d just reinserted a cannula, for the third time, in a patient who seemed intent on pulling out all my glorious efforts the minute my back was turned, and I was going to make a pit stop at one of the vending machines when my bleep went off.
It was A&E. It was most likely a new admission, or someone who needed their medication writing up, and I stopped at a phone in the corridor in order to call them. It was my registrar. This was the first time in three nights he’d got in touch with me.
‘Could you come down to the emergency department?’ he said.
I couldn’t imagine what he wanted. Some registrars liked you to write in the notes as they spoke, or prescribe all the patient’s medication, but this registrar seemed happy to do all of those things by himself. Perhaps it was a big emergency, I thought. Perhaps it’s something important and he needs my help. I quickened my pace, fully expecting to walk into the scene of a major incident as soon as I pushed open the double doors to A&E. There was nothing. If anything, the department seemed quite peaceful. A couple of staff were restocking one of the trolleys and Claire was sorting out a medical bed for a new admission. She turned and smiled at me.
‘Everything all right?’ she said.
‘Yes,’ I said. ‘Yes, everything is fine.’
I looked around the department and spotted my registrar sitting at the main desk, leaning back with his hands laced behind his head. He gestured to another chair and I sat down.
‘Everything all right?’ he said.
‘Everything is fine.’
‘Are the wards okay?’
‘The wards are fine,’ I said and I frowned at him.
‘I’m going to Amsterdam,’ he said.
I frowned a little harder. He’d bleeped me to come all the way to A&E purely to talk about a holiday he had planned?
‘Right,’ I said slowly. ‘That’s nice, when are you going?’
He leaned forward and smiled. ‘Now,’ he said.
I waited for the punchline. There was none.
I stared at him. ‘What do you mean, now?’
He pushed something into my hands and I took it without looking down. ‘I mean I’m leaving now,’ he said. ‘You’re in charge.’
There was a wave of anxiety so terrifying it pushed bile into my mouth.
‘You can’t just leave,’ I said. ‘I can’t be here all by myself!’
He stood up. ‘You’ll be fine.’
‘But there’s six hours left of the shift!’
‘If I don’t go now, I’ll miss my flight.’
He started to walk away.
‘You can’t just leave!’ I said again, only this time I shouted it.
Claire, who had heard the whole conversation, shouted to him as well.
He carried on walking. He even waved at us, without turning, like Liza Minnelli in Cabaret.
He was gone.
I looked down to see what he’d given me.
It was a bleep. His bleep. The same bleep I was supposed to call if I was in trouble, or felt out of my depth, or needed help. The bleep everyone else in the hospital called if there was a surgical emergency.
I held it in my hands.
It belonged to me now.
I had been a doctor for ten days.
Within three minutes, the paramedics had arrived with an emergency, sirens and lights and a crash of doors. My registrar must have driven right past them on his way out of the hospital car park.
It was a young man with severe abdominal pain and vomiting. He also had learning difficulties. He had a long and tricky cardiac history, and multiple other health problems running alongside, and if that weren’t enough to make things complicated for him, and also for us, he had a permanent tracheostomy. He was in severe pain. He was understandably frightened and he was thrashing around on the trolley, kicking and punching each time anyone went near him.
The A&E consultant shouted from somewhere in the middle of a crowd of people.
‘Where’s the surgical team?’
I felt the weight of the bleep in the pocket of my scrubs and I took a deep breath and swallowed back the bile.
‘I am the surgical team,’ I said.
I watched from the corner of the Resus room as the A&E staff stabilised him. They monitored his heart and his breathing, they got his pain under control, and they managed to calm him enough to examine him and take bloods. I watched in awe at their skill and their expertise, at their kindness and understanding, but also with a huge weight of guilt and deep anger that this young man was not getting the surgical doctor he was entitled to. He was never put in any danger and he was never neglected, but he deserved better than me. At that moment it felt like every patient in the hospital deserved better than me.
The A&E consultant walked over to where I was standing.
‘He needs an ITU bed,’ she said and looked at my badge. ‘Where is your registrar?’
‘Amsterdam,’ I answered, because there wasn’t really anything else I could offer.
‘I’ll get him an ITU bed,’ said a voice from across the room.
It was Claire and she did exactly that.
I watched the young man being taken away by the porters. He also had a nurse and an emergency department doctor with him, and his trolley was littered with so many wires and so much equipment that it was difficult to tell if there was a patient lying among it all.
The sense of relief made my legs unsteady. He belonged to someone else now – someone far more capable than I was – and I could go back to my own job, because, while the registrar’s bleep had stayed eerily silent while I was in Resus, my own bleep had gone off so many times that some of the numbers couldn’t be stored and they were erased forever. It wasn’t a problem. There was no doubt in the world that they would bleep me again.
I worked my way through the phone calls, prioritising jobs, talking to nursing staff. All the time I thought about the young man and I wondered how he was doing. Ten minutes later, my bleep went off yet again. It was ITU.
‘This is the on-call doctor from ITU. We have your patient,’ said a woman’s voice.
She put a particular emphasis on ‘your’.
I hesitated. ‘Yes,’ I said.
‘I just wondered,’ said the doctor, ‘would you like me to prescribe all his regular medication?’
I hesitated again. Would he be having surgery tomorrow? Was any of his medication inadvisable if he was? What about the drugs he had in A&E – did any of them mean he shouldn’t have his regular medication alongside?
I didn’t know. All of it would be written in his notes, which were now in the hands of the doctor who was calling me. This doctor also happened to be an ST5, and, in the strangely labelled hierarchy of doctor training, that meant she was at least five years more experienced than me.
‘I don’t know,’ I said.
She put the phone down.
Ten minutes later, she bleeped me again.
‘Would you like me to put a nasogastric tube down?’ she said. ‘To feed him?’
There was silence. It felt like an exam.
‘Does he need a chest X-ray?’ she said.
Still silence.
‘He has a tracheostomy, is a chest X-ray still necessary?’
‘Yes,’ I said, but I turned it into a question.
She put the phone down again.
This went on through the night. Every twenty minutes I would be bleeped with a question or to tell me a pulse rate or a blood pressure reading; to ask me what she should do, even though her experience meant that she was more aware than I was of what was needed. When she had drawn out my ignorance and highlighted my complete lack of knowledge, she would replace the receiver without speaking. Clearly, this woman was having just as bad a night as I was, but it felt like I was being punished. It felt like bullying.
Twenty minutes later, my bleep went off again. I presumed it was my next set of impossible questions, my next round of punishment, but it wasn’t. When I checked the number, it was one of the wards.
‘Can you come to Ward 11?’ said the nurse. ‘Can you come straight away?’
It was the woman in the side room, the one on my list who had held on to life for another day. At five o’clock on an August morning, her body had decided it was time to leave.
It was not an easy journey. The cancer she had endured had marched through her body, taking her organs one by one, burrowing deep into her bones and spreading itself throughout her brain. She had pain relief and anti-nausea medication prescribed, drugs to help with her swallowing and her anxiety, but it wasn’t enough. I could hear her cries as I walked down the corridor towards the ward.
‘Could you give her some more morphine?’ said the nurse.
I looked at the woman’s drug chart. She was almost up to the limit of what I was allowed to prescribe, but I could risk a little more.
We waited in silence, the nurses and I, sitting in pools of light made by the night lamps on the desk. The crying continued.
Let me die the woman shouted from the side room, please just let me die.
We waited. Perhaps it needed time to kick in.
Please just let me die.
‘Can’t you prescribe any more?’ the nurse said.
I solemnly pledge to consecrate my life to the service of humanity.
I looked at the drug chart again. The woman was on the maximum dose allowed. If I wrote up any more, not only would it be illegal, it would look as though I had deliberately put an end to her life. It would look as though I’d killed her. Her relatives were on their way, what would they think if I prescribed too much? What would they think if I didn’t?
‘I can’t,’ I said. ‘I’m not allowed to.’
Please just let me die.
‘Where’s your registrar?’ she said.
‘He’s gone to Amsterdam. He’s disappeared in the middle of the shift and left me. I don’t have anyone else. I’m on my own.’
‘Then it’s down to you – she needs more pain relief.’
Please just let me die.
I stared at the drug chart. What should I do – should I stick to the rules or should I write up the morphine and face the consequences later? If this was my mother, wouldn’t I give her all the morphine in the world, just to put an end to her misery? Was I putting myself and my own survival before the needs of a patient?
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.
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.