There is a running joke that you should avoid being admitted to hospital at the beginning of August, because that’s when all the new doctors arrive on the wards. In truth, it’s the very best time to be admitted, because what new doctors lack in experience they make up for in enthusiasm and compassion. They are yet to be worn down by frustration and tarnished by a broken system. They answer their bleeps immediately, they have time for everyone. They care. There are a few who think nurses are beneath them, but we have ways of putting them right on that score.
The nurse
On a bright, sunny morning in August, the machinery of the NHS turns and all the junior doctors change jobs.
Amid that change, a new harvest arrives, filled with enthusiasm. They are processed, inducted, initiated. They collect bleeps and lanyards, swipe cards and pagers, and they disappear into the wards and along the corridors, where they are swallowed up into the hospital.
I had spent the previous two weeks ‘shadowing’ my predecessor, a young woman grey with exhaustion and worn down at the edges, who tried to pass on a stream of insider tips for survival, as a parent would to a child.
‘The vending machines upstairs never work,’ she said.
‘Don’t rely on the cashpoint near the porters’ lodge, because it’s always broken.’
‘The nurses on Ward 4 are the nicest. They’ll make you a cup of tea.’
She told me which consultants were religiously early, and which consultants started a ward round ten minutes before you were due to end your shift. Which consultants you could go to with a problem, and which were best avoided.
‘Don’t go near her when she’s wearing black,’ was all she said about one.
She showed me the telephone system and the layout of the wards, how to order an X-ray and how to check blood results on the computer. Extension numbers, requests for porters, paperwork and pharmacy. What to do if you get a needle stick injury. Where the death certificate book is kept. The best parking places. The quickest route from the mortuary to the doctors’ mess. I wrote some of the things down and the rest I tried to commit to memory. Like a Labrador puppy, I trotted behind her all day and watched from the safe shelter of the periphery.
On my first day, of course, she had gone.
My job was in urology. A magical mixture of bladders, testes and ureters. There was everything from kidney stones to testicular cancer, enlarged prostates to difficult catheters, and, alongside them, an endless supply of elderly patients who – for a wide variety of usually mysterious and unexplained reasons – had stopped being able to pee.
Surgery days always begin earlier than medical days, and at seven-thirty I arrived for my first shift as a doctor, allowing myself an extra half an hour to find a free computer and print off my patient list, which would eventually turn out to be the first challenge of any morning. The ward round began at eight sharp and this gave me just a couple of minutes to spare in which to congratulate myself for finding the right ward, and for making it on time and with all the various bits and pieces I needed to have about my person.
Surgical ward rounds are fast. Unlike medical ward rounds, which often pause for reflection and conversation, and sometimes last all day, surgical ward rounds are swift, clean and unfussy. Surgeons belong in theatre, and I often wondered if some of them saw speaking to patients as more of a sideline. A minor distraction before the real work began. The consultant coasted through the ward, occasionally stretching out a hand for a set of notes or an observations chart. We scrambled behind him, trying to keep up, arguing with unruly cubicle curtains – which were no sooner drawn to than he was on his way again – and the notes trolley became a vehicle of chaos. We each had a job on the ward round, and mine was to prescribe the medication, which was all done electronically. I could barely remember my log-in details, let alone my PIN number, and I couldn’t hear what the consultant was saying above the noise of the trolleys and the breakfast plates. I didn’t dare ask him to repeat it. The laptop teetered on the edge of a tower of notes. People moved it to retrieve those notes and it shut itself down. I managed to restart it and log myself in, but it was borrowed and taken away, and someone else logged me out. I tried and failed to put my details in again. The laptop became very angry and locked me out of the system altogether. I began to shake. The senior house officer (SHO) leaned over and pressed a few keys. He typed in all the prescriptions that were needed in a matter of seconds, and when he finished, he looked at me.
‘Don’t worry,’ he said. ‘It gets better.’
At the end of the ward round, the consultant disappeared to theatre and the rest of us were left in the wake of a tornado, with a jobs list to divide up between us. There were notes to write, discharge letters to type, medications to change and blood tests to chase. Everything in medicine is chased. Chase that, a consultant will say, tapping at an X-ray report or a bloods request, and you will find that your to-do list is mainly comprised of things you are required to run after. It was a list that stretched across the day and late into the afternoon.
My predecessor was right, though. On Ward 4, the nurses do always make you a cup of tea.
By the end of the first week, the SHO’s prediction came to pass. It did get better. I learned my log-in details by heart. I knew to be prepared, and to prescribe ‘as needed’ pain relief and anti-sickness for anyone returning from surgery. I knew to clip consent forms to the front of notes and to make sure no patient was ever sent to theatre without a cannula in place. I began to feel more relaxed. Bedded in slightly. Perhaps even a little bit useful.
Unfortunately, though, medicine never allows you to relax for very long, because no sooner had I completed a week of day shifts than the timetable changed again. I was about to roam the corridors alone for hours at a time, not only called upon for my own patients, but for any surgical patient in the hospital.
I was about to start my first set of nights.
The hospital at night is a different country. The first thing you notice is the absence of sound. In the day, there is a white noise of trolley wheels and telephones, conversations and footsteps, and on every corridor great waves of people move towards you – nurses, doctors, porters, cleaners. The crash and clatter of laundry carts and meal trays. The reassurance of sound. During the day, there is no corner of the building where you are able to find even a small space of silence.
At night, everything is made out of silence. Not until noise is removed do you appreciate how comforting it is to hear the distant work of other people. Apart from a trickle of evening visitors, heading back towards the car park, I saw no one on my walk to handover. The shutters were down on the little shops and at the florist’s, and upturned chairs rested on the coffee-shop tables. A row of secretaries’ offices, usually an engine of efficiency, all stood in darkness. Computers sleeping. Mugs rinsed on draining boards. Tea towels folded. I passed A&E, a place where the terms day and night cease to have any meaning, and the bright lights and sound of people talking provided a small consolation. I was not alone. There were other doctors scattered around the hospital, and among them, somewhere, was my registrar. The person I turned to if I needed help or if I felt out of my depth. All I had to do was call his bleep and he would be there.
Evening handover was held in a small teaching room on the top floor. I was the first to arrive and I waited in the hum of a strip light, alongside a broken projector screen and a plastic skeleton. To pass the time, I stared at the list of symptoms written on the whiteboard and tried to work out what had last been taught, but the notes made no sense to me. My inability to recognise them sent me into a small panic. What was I even doing there? I knew nothing. I was a fraud. A charlatan. It felt as though, at any moment, a GMC police officer might march through the door and arrest me on the spot for being an interloper. I took a small collection of talismans out of my pocket for reassurance. My stethoscope, a notebook and pen, a laminated card of out of hours bleeps – pathology, radiology, ECGs and the ever-present portering services – and a long list of extension numbers for every ward in the hospital. I took out my tourniquet, which had cartoon bats printed on it and was clearly designed for paediatrics. When I’d bought it, it had seemed amusing, but in the stark light of that teaching room it felt almost grotesque. Lastly, I had a reference book, a handy guide for junior doctors that we all carried around with us: bullet-point lists of what to do and what to check and what to prescribe in different situations, as if all of life’s emergencies could be condensed into a small handbook and stored neatly in your pocket.
The outgoing doctor arrived to give me the on-call bleep. He apologised for the long list of jobs he was about to read out, because there is an unspoken rule in medicine that you don’t hand over jobs in handover – a rule which is impossible to follow. His scrubs were creased and tired, and he looked as though he hadn’t slept for a week. The bleep sat between us. It went off six times while he was talking, because, as I would very soon learn, the silence of the hospital at night is just a smokescreen, and buried somewhere in that silence there is the never-ending sound of small tragedies.
The only other person present in handover was the site nurse practitioner, one of the most experienced nurses in the hospital, who patrolled the wards during the night assessing the most unwell patients, alerting the staff to any problems, sorting out beds and difficult cannulas, ensuring the hospital ran smoothly, and tidying up after the doctors. I didn’t know it then but she would be my guardian angel, her name was Claire and the fact that she was Irish just added to the sense of relief. I would have quite liked Claire to follow me around for the rest of my life, giving me a gentle push to believe in myself and a hug of reassurance when I needed it.
After they left, I sat alone studying the list of jobs I had been given. The bleep went off three more times. I rang all the numbers and added more jobs to my list.
A lot of medicine is learning how to prioritise, to decide which patient needs to be seen first, purely from a quick phone call. Is it the man on Ward 4 whose blood pressure has dropped? Is it the woman on Ward 7 with a temperature? Is it the patient who has just arrived in A&E with a short history of vomiting and abdominal pain? I learned as I walked the corridors, and I slowly began to develop an instinct, a sixth sense that told me which patient I needed to see first. Sometimes, I was wrong, but the more times I got it right, the more my confidence began to grow.
I didn’t hear from my registrar. I caught a glimpse of him occasionally, when I passed through A&E, but our paths never crossed. As well as developing an instinct about the patients who needed me most, I also learned that there are different kinds of registrars – those who enjoy bleeping you every hour to find out exactly what you’re up to, and those who like to walk the corridors alone.
As the night continued, staying awake began to be an issue. While adrenaline had kept me going for the first few hours, a broken, anxious sleep the day before meant that by 3 a.m. I had started to flag. I foraged from vending machines. Rich chocolate and paper-cup coffees. Crisps and little pots of cream cheese. Even in the brief moments when I hadn’t any jobs to do, I walked the corridors to stop myself from falling asleep, and, in an act of desperation, I stepped outside the doors of A&E and took in a huge lungful of cool night air to wake myself up. There were no on-call rooms, no beds put aside for night doctors, and all over the hospital, bodies of sleeping medics littered waiting-room sofas and office floors, as they tried to catch a twenty minute nap, their bleeps pressed into their faces. I didn’t dare. What if I couldn’t wake up? What if I slept through until morning and was discovered by a cleaner stretched out on the carpet? What if someone died?
The night walked on. I reinserted cannulas in darkened bays. I prescribed sleeping tablets, reviewed patients, took bloods ready for the eyes of the morning teams. I ordered ECGs and put catheters in. I walked cultures down to pathology. Somewhere along those corridors, somewhere between the hours of midnight and six in the morning, I began to feel useful. I felt as if I had a purpose. For the first time, it seemed as though all that training had grown into something worthwhile and I began to feel like a doctor.
There is a point on a night shift when one day turns into the next. It seems to rest on only a fraction of time. The first laundry truck appears. You catch a glimpse of a cleaner along one of the long corridors. The sounds and smells of breakfast drift along the walkway leading to the canteen. It’s not just the people and the increase in activity, though, it’s more to do with a change in the air, a sense that the building is stirring and waking to a new day. As the giant clock in A&E clicks from one second and into the next, there is a brief moment of limbo – a grey space of nothing – and then morning appears to take over the reins.
I had survived my first night shift. Despite the tiredness, I was elated.
My second night shift went just as smoothly. There were a few admissions, a few unwell patients on the wards who needed reviewing and monitoring, but, other than that, I continued with my on-call staples of cannulas and bloods, sleeping pills and pain relief.
I met my registrar, quite accidentally, in the corridor leading to the orthopaedic ward.
‘Everything okay?’ he asked.
‘Everything’s okay,’ I answered.
It was the only time I spoke to him all night.
By the third shift, I had shaken off almost all of my anxiety. I parked my car and practically marched towards the hospital entrance. I was smiling, at ease. I was almost looking forward to it.
I didn’t realise I was about to experience the very worst night of my life.