NHS
Exemplary service
We all know about the devastating effect of the pandemic on NHS waiting lists, and doctors’ appointments, and cancer diagnoses and treatment. We’ve all been aware of the changed rules of engagement for going into hospitals; some of us even fell foul of the policies that kept us from visiting our loved ones in hospitals and homes, denied us opportunities to say those last goodbyes.
So I’ve been staggered by the ongoing care I’ve received as an outpatient myself. Four and a half years ago I was diagnosed with cancer and had two surgeries to treat it. Because it was one of the more virulent and life-threatening forms of malignancy, I was told I would be monitored closely for five years, and given contact details for specialists whom I could ring if I was worried about anything between appointments. Initially I was seen every three months, and then gradually the time periods extended. Then the pandemic struck and so many routine appointments were cancelled. But mine were continued. When complete lockdown was in place I was given a consultation by phone, but once restrictions lifted sufficiently, the team felt I should be seen in person, and real appointments resumed. Last week I had my penultimate consultation.
To be honest I should have been perfectly satisfied if they’d said, just contact us if you’re worried. Indeed, I’ve felt guilty about taking up a valuable slot in a beleaguered health service, and told them so. But they’ve been adamant; each check is important, my welfare is important. I am both impressed and grateful. They have done all the worrying for me.
So it was perhaps serendipitous that, this latest visit, I took with me to the clinic waiting room a slim volume about a woman who worries about everything! It’s The Purveyor of Enchantment by Marika Cobbold – an undemanding read, requiring little concentration.
Clementine Hope, thirty-six, large and newly divorced, is a piano teacher and pathological worrier. She inherits a house, a stack of unfinished fairy tales, and an inferiority complex from her Aunt Elvira. Her half-sister Ophelia is younger, smaller, calmer and saner, and she despairs of Clementine’s fears and negativity.
When Clementine, after a failed relationship, determines to take herself in hand, she goes overboard in the risks she takes. Why does she have to be so extreme? a friend asks. Her reply: ‘I think you have to be to arrive in the middle. It’s a question of adjustment. I’ve been living a life confined by petty fears. Now I’m trying to be magnificently bold in order to finally arrive somewhere in the region of normal and sensible.’ Magnificently bold or magnificently stupid it may be, but her homespun version of aversion therapy does the trick: her fears recede and she reaches for a different future where she is in control … in spite of Ophelia.
Needless to say, I didn’t read the whole book waiting for my appointment! Conscious of the importance of limited time and space in the socially distanced chairs, appointments are now super-efficient. Hats off to an excellent department and its team of committed staff. And the book? Well, it’s on its way to the charity shop. Not one for my shelves, I’m afraid.
Theory versus practice
There’s nothing like experience for teaching you that theory only takes you so far.
For a few weeks now I’ve been living through a situation that in essence could well be fraught with ethical difficulties and conundrums. My sister had a catastrophic stroke in mid-October. She is now without the power of speech, paralysed, and with limited capacity to comprehend fine nuances. Totally dependent on others. Extremely frail with multiple co-morbidities. Furthermore, at times, she has appeared unaware of her surroundings and unresponsive to conversation. Unreachable.
I am her next of kin and her authorised health proxy. She and I together made sure some years back that we had all the paperwork for this in place; signed, sealed and delivered. We also prepared her Advanced Directive, revisited several times to ensure it represents her sustained wish. I am confident it does.
So, here we are, in one fell swoop, in exactly the kind of situation envisaged when the directive might become critical to decision making on her behalf. The consultant taking care of her in the first few weeks has been exemplary – a brilliant communicator as well as so kind and caring. He and I talked about the directive, and a copy is in her medical notes.
But, when exactly does the theoretical become the real? When does treatment become more burdensome than beneficial? When does the prospect of a life of dependence and indignity become so bad that death is a better option? Who is going to suggest withholding medication in a crisis to ‘let nature take its course’? At what point does someone start that conversation? And who should have the casting vote?
We aren’t there yet. Currently we’re tiptoeing along establishing baselines, testing limits, waiting, watching, thinking. And right now, this week, starting all over again communicating remotely with a new team of professionals in a different ward since she tested positive for Covid-19. Putting someone’s wishes into effect in these circumstances is a far far harder thing in reality than in theory. And I’m so grateful for people like our dedicated consultant with experience and wisdom to guide us. The NHS has come in for some heavy criticism over the past couple of years; I want to shout out for people like him, like every person in the vast team who has made a difference in the care of my beloved relative … a patient who ticks none of the celebrity high-profile boxes, but who has all her life made the world a better place.
Our NHS – what’s it worth?
Well, I don’t know how you feel about the proposed pay rises for NHS workers announced last week, but for me there’s an uncomfortable mismatch between the plaudits and superlatives and clapping during lockdown, and the value of the suggested tangible ‘rewards’ now. These people who save the lives of strangers, and treat our sick neighbours, and care for our children and our grannies, and keep vigil with our dying, are demoralised, exhausted, burnt-out, and now feeling undervalued.
I’ve recently shared on this blog several new publications about life on the frontline written during the pandemic, but I wanted to remind myself of the commitment and dedication health care practitioners always show, day after day, year after year, so often unseen and unsung. 
So, I turned to an old book on my shelves written long before anyone had ever heard of Covid-19 – A Paramedic’s Diary: Life and Death on the Streets by Stuart Gray (2007). Gray – who hails from Glasgow originally – came to the health service relatively late, having been a professional musician, dabbled in business and computers, and completed a three-year stint in the Royal Army Medical Corps, and he brings an interesting perspective to the experiences he relates.
You couldn’t get much busier than the streets of London, and I’ve often wondered how on earth service vehicles ever get to the emergencies there. London is Gray’s stamping ground, but far from lamenting traffic issues, he concentrates on the human obstacles to delivering the care he’s trained to administer: ‘ignorant time-wasters’ he calls them, who stop him from saving other lives.
People who dial 999 …
for a broken fingernail,
or for help to wrap Christmas presents,
or to move furniture because the feng shui isn’t right,
or to be helped to their bed (because they’re vastly overweight).
You couldn’t make it up!
Then there are the hoax callers who attack or abuse the crews when they turn up, the drunks who have to be removed from buses or out of the gutter, the drug users and any of their cronies who might be lurking in the shadows with malicious intent.
Not many of us joined this profession desperate to wade through as much drink, vomit and stupidity as we could. Most of us are here to care for people who really need it, not selfish self-harmers who go out of their way to blitz the system with their lifestyle problems.
My colleagues and I stand in the wasteland of other people’s lives and watch as they destroy themselves in a bottle.
At the other end of the scale he cares nothing for the inconvenience or danger if the call is legitimate. His commitment shines through as he describes the awesome responsibility of attending a birth, of comforting a mother with a dead baby, or dealing with someone traumatised by a miscarriage. He’s even been known to weep himself once he’s back at home re-living the emotion.
He’s moved by the poignancy of scenes of normal everyday activities like shaving or getting dressed or going shopping – activities which will now never be undertaken because the person who intended to do these things has suddenly left this world. He grieves, not only for the lives cut short by sudden medical catastrophes or accidents, but also for the relatives whose lives have been irrevocably changed in an instant.
Experience has taught him that much can go wrong with attempted suicides. He’s seen at first hand the mess of a botched job, or an incomplete death under a train or a bridge or at the end of a rope. He’s sat alongside people who’ve witnessed suicides, traumatised beyond coherent speech. And he’s all too aware of the risks to paramedics of electrocution, or crushing, or being trapped. To this day he refuses to stand near the edge of a station platform, all too aware of the possibility of being accidentally pushed (I thought I was alone in this obsession). There are enough dangers already in his job.
The hours are long, meal breaks often missed, the pay not commensurate with the tasks undertaken.
EARLIES. Shifts which start at 6.30am, or 7am. They usually present a slower start because people are not yet up and around so they aren’t trying to kill themselves by falling, crashing, running into brick walls, arguing with their drunk neighbours or mainlining speed. You get to see daylight and it’s safer than working late at night. You might even get breakfast.
These are the everyday incidents that make up the working lives of paramedics. Highs and lows, successes and failures. Sights and smells – ‘outrageous’, ‘hellish’ – that few of us could tolerate. But Gray has had his moments of high drama too. He was part of the massive emergency response to the 7 July 2005 (7/7) terrorist attack when three bombs exploded on three separate tube trains, and a bus was blown up in Tavistock Square (medical colleagues of mine were yards away from this one so it’s vivid in my memory). As fast as they could ferry critically ill patients to hospital, the paramedics were sent back out again and again to carry more casualties. ‘It felt like a war zone.’ Some were risking their own lives, alongside the police and firefighters, to get to the injured and dying deep underground.
In spite of it all, the good, the bad and the ugly, Stuart Gray loves his job. It’s ‘almost addictive. It gets under your skin.’ It’s ‘exciting … varied … allows me the honour of walking across a stranger’s threshold and into their private lives.’
What kind of pay rise do YOU think such professionals deserve? And the nurses and doctors who continue where the paramedics leave off – dealing with the vomit, the faeces, the blood, the brain matter, the human emotion, the abuse, the violence, the massive responsibility, the guilt, the dread? What are these amazing people worth?
Many Different Kinds of Love
Listening to Michael Rosen speaking at the Hay Festival was enough to make me immediately order his book about surviving Covid: Many Different Kinds of Love. And read it as soon as it arrived! It’s an account like no other.
He was a whisker away from death because he didn’t fit the criteria (at the time) for serious illness. But thanks to the intervention of a skilled and determined GP friend, Michael bypassed inappropriate advice to stay at home, and was whipped into hospital with a dangerously low level of oxygen in his blood. So ill was he, indeed, that he spent 47 days in Intensive Care, much of it in an induced coma on a ventilator.
During this time, even though they were working ridiculous hours under extreme pressure, often way outside their comfort zones, the staff took the trouble to pen personal, encouraging, reassuring messages in a diary. Their entries make fascinating reading. Learning of their care, seeing them in action, Michael was reduced to tears by their devotion and love; it was akin to that of a parent keeping vigil with a sick child.
‘They aren’t my parents … It’s a kindness I can hardly grasp.’
Michael was, of course, a celebrity patient, a well known and loved children’s author and poet; they were willing him to return to his natural milieu of writing and performing again for others.
Reading their words, I was personally struck by the vast range of occupations these novice writers came from. Here they were in a high-tech, fast-paced, highly specialised environment, a unit packed to the gunnels, surrounded by patients presenting with a hitherto unknown infectious disease affecting multiple systems, and they were, in their other lives, speech and language therapists, physios, children’s nurses, school nurses, infection control personnel, urology specialists, even dental hygienists! Mind-blowing!
After ventilation, Michael spent another long period hovering somewhere between life and death, and it was his wife, Emma, who brought him through to the other side of this, surrounding him with love and the favourite soundtracks of his life.
It was only then, as he re-entered consciousness and self awareness, that he could pick up the threads of the story for himself.
Reviewing that time while he hovered on the brink of life/death, he himself could see the humour in his situation.
Of the constant monitoring he says:
There is now a ledger telling
the story of my ups and downs.
I have become an account.
He was mesmerised by the multiple tasks these caring hands accomplished.
Your hands speak.
Touch is a language.
Each palm
each fingertip
is a line from your stories.
He saw the ‘Land of the Dead’ as having taken bits of him prisoner. (His left eye and ear are still markedly impaired.)
They’re waiting for me to come back.
The ear is listening.
The eye is the lookout.
Recovery of strength and will power became a painful inch by inch struggle. Early on, trying to will his leg to move, was like speaking to a blank space.
As he improved physically he became alive to humour around him.
The nurse tells Peter in the bed opposite,
that his urine is dark.
‘The times are dark,’ he says.
But at each stage of progress Michael feared this was as good as it got …
… now in a wheelchair – is this me?
… using a zimmer frame – is this me?
At intervals: I’m not going to get better – am I?
… remaining on one level in the house – I’m 74. Maybe I’ve become a kind of 90 ...
Watching and listening to the monumental struggle made me value in a new way his personal appearance at the Hay Festival this year. He had learned from OTs how to own his frailty.
And when he eventually went home:
I am not sure I am me.
I can’t see as I used to see.
I can’t hear as I used to hear.
My legs feel like cardboard tubes,
filled with porridge.
And ‘I’m not sure I am me’ became a bit of a refrain.
But he did get home and little by little he did gain strength and mobility. Returning as an outpatient:
Woman at the door asks me
if I want anything sharpening.
My wits, I say.
(I didn’t.
My wits aren’t sharp enough.)
By now you’ll have got the sense of the style of writing – short staccato entries, written as poetry, as if that is all his recovering brain could handle. Lots and lots of white space. But underpinning it, the irrepressible wit and wisdom for which he is known and loved.
All perfectly illustrated by Chris Riddell‘s wonderfully evocative and delicate pen and ink drawings.
I was pleased to see that, even though he’s so conscious of the great debt he owes the NHS, Michael’s not afraid to criticise the government and scientists where they got it wrong. Perhaps he sums up the whole handling of the pandemic as well as his personal progress when he says:
And it never stops:
we are always becoming.
Sobering realities from the Covid-19 frontline
I love the idea of a story about a detective hunting lost triangles! A man whose imagination conjures up that plot for his children has my ear!
A doctor who lets his small daughter paint his toenails lurid colours during a pandemic and leaves it on – It’s a little piece of home to take to work, a talisman to protect me and a token to remind me – gets my attention.
One who’s fearless enough to spell out unpalatable facts about our health service in the face of repeated political assurances of world-beating everything, gets my vote.
And when that medic is so incensed by the government’s spineless response to Special Advisor Dominic Cummings’ blatant disregard for instructions to the nation during lockdown, that he tweets a photo of himself in full PPE, stating that if Cummings doesn’t resign, he will, and then does so, has my heartfelt respect.
That man is Dr Dominic Pimenta, Specialist Registrar in cardiology. His story in Duty of Care begins in London in January 2020, when he becomes increasingly aware of a tsunami of disaster heading this way. It’s the stuff of his nightmares.
The book is certainly not comfortable reading. It exposes a stark picture of our country woefully lagging in health care provision:
The simple numbers are so bad they speak for themselves; at present, we have the worst A&E waiting times on record, the worst operating waiting times and the worst record on hitting targets. Even life expectancy is on the decline. We are short-staffed by a figure of around 100,000 staff, including 40,000 nurses. We also have one of the lowest number of critical care beds, general hospital beds and doctors per head of all the 37 countries in the Organisation for Economic Co-operation and Development (OECD). If we were an army, we would be a band of bedraggled, starved and exhausted soldiers. And that was all the case before any sign of coronavirus.
Now, I must confess that I personally have a lot of sympathy for our leaders trying to steer a course between many competing demands, balancing livelihoods against lives, damned if they do, damned if they don’t. It’s all too easy to criticise from the sidelines, or with hindsight. I cringe watching opposition MPs constantly carping about the decisions of government, knowing full well they aren’t going to be held accountable themselves. But this man, Dominic Pimenta, is a medical practitioner, and he had his eyes wide open from the outset. He isn’t scoring political points. So when he catalogues a litany of failings – incompetence, mendacity, lack of transparency, disregard of WHO advice – which have led to thousands of people losing their lives, thousands losing loved ones, thousands developing serious health problems, thousands having vital treatments postponed, thousands suffering serious mental ill health, then we ought to sit up and take note. These are desperately serious consequences indeed.
We could see the pandemic unfold, in high definition, live, 24/7, before our very eyes. And yet, for too long, we did nothing at all.
But in spite of his acute awareness of the true picture, shining through is his pride in the NHS: they responded magnificently to an overwhelming situation. He outlines convincing detail of their titanic struggle, their frustrations, their failures, as well as their triumphs and heroics.
With the right mindset, we are capable of incredible things.
Amen to that.
His own personal energy and determination to make a difference are exhausting to contemplate:
– writing articles spelling out the coming danger
– tweeting analysis and warnings
– publishing in the national press
– appearing on live TV shows
– campaigning for change
– garnering signatories for public appeals
– establishing a charity, HEROES, (now rebranded as Healthcare Workers’ Foundation) for the protection and support of healthcare workers
– attracting celebrity support
– designing prototypes for PPE (personal protection equipment)
– setting up a second organisation, SHIELD, to bring industry leaders and experts together in the creation of innovative solutions to meet the demand for PPE, including cutting edge ‘printing hubs’ …
all while working as a clinician way outside his own comfort zone – at the frontline in ICU – and trying to be a husband, father, brother, son, uncle, friend, in unprecedented times. His manic activity leaves one fearful for both his mental and physical health, but as he says himself, the problem was so vast, it would never feel as if any level of effort was enough.
In Duty of Care he leaves the story at the end of the first lockdown, knowing a second and possible third tsunami are coming. Since he published it, we have all entered that predicted second wave and are dealing with its consequences right now. This week the death toll in the UK passed 62,000. I feel fairly confident we’ve not heard the last from this extraordinary ma, but I leave you with his own parting shot:
So stay informed, stay safe and be kind.
Whistle blowing
To err is human, to cover up is unforgivable, and to fail to learn is inexcusable.
Prof Sir Liam Donaldson (former CMO England)
Whistle in the Wind has to be the most disturbing book I’ve read this year – and probably not best tackled when we’re all rather dispirited about the rising Covid numbers, and increasing restrictions on our freedoms. Hey ho! Once started I couldn’t go back.
It tells the story of one NHS senior consultant surgeon’s battle to get his hospital/Trust to take action in the face of a catalogue of failings and dangerous practices in his place of work – abysmal clinical standards, gross imbalances in workload, extremely poor judgements, shirked responsibilities, dysfunctional relationships, financial irregularities. But the ‘guilty parties’ resented Peter Duffy drawing attention to their deficiencies, and mounted a deliberate campaign of victimisation and counter accusations against him.
At the time, the Trust’s website declared that no whistle-blower would lose their job or suffer any detriment if they spoke up to identify genuine patient safety concerns – a claim made by most large organisations nowadays. But the reality was far from the promise. Even more unbelievably, the same Trust had recently had its Midwifery Department found guilty of gross and shocking failings, a fact plastered over the media, but senior management nevertheless still appeared complacent and apathetic. Ranks closed. Honesty and truth were stifled.
Hugely daunted, Mr Duffy nevertheless eventually reported his concerns to the Care Quality Commission whose job it is to oversee safe and effective practice in health and social care settings. Until I read this book, I thought they were indeed the go-to organisation for action and a fair independent hearing. But in his case, they didn’t even attempt to corroborate his account. And furthermore, they specifically state that they will take no part in protecting the individual whistle-blower. Who knew?!
Retaliatory action against Mr Duffy escalated, and included not only malicious, false, fabricated and covert accusations – defamatory emails and letters claiming he was both racist and a bully, and had fraudulently obtained money to which he was not entitled – but also docking a substantial sum of money owed to him, and eventually loss of his job. Accusations against him were sent to the police as well as senior management. He even received a phonecall warning him that the consultants he had reported were ‘utterly committed to revenge’. He felt ‘thoroughly hated and despised’.
In spite of his senior status and established good reputation, no one in any of the organisations set up to deal with such situations seemed to be paying any attention to his legitimate and proven concerns. There was no feedback, no support, no action.
How this man coped with seeing continuing incidences of neglect, malpractice, avoidable harm or deaths, on top of the personal vendetta against him, I really don’t know. I once blew the whistle in a much more low-key way and suffered from the aftermath of the ensuing hostility and injustice for years. Reading this book stirred the embers of that horror quite stressfully. Finally, even Mr Duffy had no appetite for submitting reports of sub-optimal care which went unheeded; he felt intimidated and frightened by the hostility and retaliation.
By now the toxicity within the hospital – ongoing rudeness, aggression, hostility, dysfunctional behaviour and relationships, collusion, incompetence, cover up, neglect, dangerous practices – together with his own fear of some act of revenge, led to his health suffering seriously. Sleeplessness and high anxiety levels led to him suffering cardiac arrhythmias, ending up a patient himself.
But his conscience and professionalism would not allow him to turn a blind eye when the lives and dignity of patients were at stake. The General Medical Council‘s position is, after all, unequivocal:
Doctors in particular have a duty to act when they believe patient’s safety is at risk, or that patient’s care or dignity is being compromised. Our guidance sets out our expectation that all doctors will, whatever their role, take appropriate action to raise and act on concerns about patient care, dignity and safety.
He felt the weight of this duty keenly.
Colleagues and friends, however, seeing how he had been treated, were reluctant to expose themselves to the same retribution. Even when his case came to an Employment Tribunal, disclosure was limited. Witnesses were warned off from supporting him; they could neither appear nor have their witness statements seen by the Tribunal. And just four working days before the case was heard, the Trust issued an intimidating letter, telling Mr Duffy he was doomed to lose his case, and they would be pursuing him and his family for costs estimated at £108,000. However, if he would just agree to drop the case immediately in its entirety, remain silent, and agree to a non-disclosure clause, then they would not pursue costs.
To his great credit, he did not give in to these strong-arm tactics. And he was eventually exonerated, but the triumph was something of a pyrrhic victory. Even though this case was deemed an across-the-board failure on the part of the Trust and the clinicians concerned, nothing much has changed, Mr Duffy laments. Systemic failures are still ongoing; lives are still put at risk avoidably; whistle-blowers are still treated as lepers. Furthermore, he and his family have paid a colossal price for his integrity, courage and commitment to patient safety. In a massive understatement, he says he still struggles to believe the tactics adopted to silence him. I recognise that sense of incredulity and bewilderment all too easily.
The NHS, regulators and the law, all repeatedly claim the importance of safeguarding and speaking out to protect others; and they have a clearly stated duty of care to clinicians and patients. They offered this particular whistle-blower neither care nor protection. I can well imagine writing this book was cathartic for its author – at last he could present his case in its entirety. And I thank him sincerely for doing so. It was, in the end, therapeutic for me too – putting me clearly into the camp of ‘committed, responsible, caring individuals’ who summon up the strength to stand up to those who hurt or bully the vulnerable. The fact that it’s not a literary masterpiece, adds to its feeling of authenticity. It’s an unvarnished, from-the-heart, account. I can only admire the persistence and courage behind it, and wish the Duffy family well in the future.
The front line: then and now
Health Minister and Conservative MP, Nadine Dorries, was the first member of parliament to be diagnosed with Covid-19. This was back in early March … at a time when there were only 382 reported cases in UK, only 6 people had died. Halcyon days, huh? Less than two months later, we’ve already exceeded 26,000 deaths!
The news about Ms Dorries triggered a memory: I’d read somewhere that she was a trained nurse, and intrigued, I’d bought two of her ‘nursey’ novels in a coffee shop on my way to Wigtown, Scotland’s National Book Town a couple of years ago, stuck them on my shelves, and promptly forgotten about them – The Angels of Lovely Lane and Christmas Angels. Time, methinks, to dig them out and read them … a kind of tribute to the nurses today working so hard to care for people with the virus in a very different world.
I must confess neither the genre, nor the style of writing, are ones I’d normally go for, but there were aspects of these books that gave me pause for thought and sober reflection. These nurses were practising not long before I trained; their experiences resonated with me. Rather like BBC1’s drama, Call the Midwife.
Reading about and recalling those days made me so grateful for all that modern medicine and social care can offer today. How far we have come from those days when
– the NHS was in its infancy
– antibiotics were wonder-drugs
– women had limited career options
– smoking was the norm
– lecture notes were written on typewriters using carbon paper
– rubber tubing was boiled before being inserted into various orifices
– patients were lifted manually
– doctors were revered and all powerful
– women died or were imprisoned following illegal abortions
– ten days bedrest was de rigeur after a simple D&C; three weeks after childbirth
– nurses wore starched collars and frilly caps, always kept their hair off their face tucked inside their caps, lived in hostels with rigid rules, and were all known by their surnames
– silver buckles on petersham belts denoted qualifications
– the Irish were openly discriminated against …
Compare all that with communication, technology, medical expertise, opportunities, science, in 2020. What would have happened if the dreaded coronavirus has struck then?
In her fiction centring on Liverpool in the 1950s, Nadine Dorries has captured a world I knew, and for a few days took me away from the uncertainties and restrictions and anxieties of our present situation, to a bygone era. Memories both happy and sad. But overwhelmingly reasons to be devoutly grateful for what’s available to us today, and the amazing work our front-line staff are doing – and are able to do – to beat Covid-19.
The sad state of our NHS
A relative of mine is currently struggling with the intransigencies of a creaking NHS. I’m doing my best to find a way through that gets the patient the much-needed attention without further demoralising a team of professionals fighting fire because of impossible targets and too few resources. After all, I, more than many, appreciate both sides: I was a small cog in the healthcare machine myself for donkeys’ years, and I’ve been on the receiving end many times too. So perhaps a book by someone who buckled under the burden of working in such an environment was bound to resonate for me.
Adam Kay‘s This is Going to Hurt is absolutely brilliant. One of a family of doctors, his ‘default decision’ as a teenager was to follow in their footsteps, but nothing prepared him for the reality of life post-qualification, the life of a junior doctor.
Recording thoughts and experiences is a recommended part of ‘reflective practice’, and This is Going to Hurt is based on Adam’s diary scribbled in secret after endless days, sleepless nights and missed weekends. It’s a no-holds barred account of his time on the front line. 97-hour weeks. Life and death decisions. Ingratitude and complaint. Raw experience. Terror. Failure. Success. Innumerable objects in assorted orifices. A tsunami of bodily fluids drenching his person and his imagination. All recounted with honest brutality and a fabulous line in whacky humour.
Kay spent six years training and a further six years practising medicine, specialising in obstetrics and gynaecology. But eventually the price he was paying was simply too high. When something terrible happened on his watch, he finally crumbled. The patient suffered a torrential haemorrhage during a caesarean section – she had an undiagnosed placenta praevia. Dr Kay hadn’t been negligent and there was no suggestion otherwise; any other competent doctor in such circumstances would have done exactly what he did. But he expected more of himself. He was the most senior doctor involved and everyone was relying on him to sort out the horror. He felt overwhelmed by the tragedy.
I knew that if I’d been better – super-diligent, super-observant, super-something – I might have gone into that room an hour earlier. I might have noticed some subtle change on the CTG. I might have saved the baby’s life, saved the mother from permanent compromise. That ‘might-have’ was inescapable.
Much like the NHS itself, the book is filled with hope and despair, miracles and disasters, catastrophes and absurdities, intense sadness and riotous gallows humour. I defy anyone to read it without laughing out loud, or more importantly, without a sinking heart. It’s a damning indictment of a system that expects its practitioners to work impossible hours, assume phenomenal responsibility, compromise their health and relationships, for less pay than ‘the hospital parking meter earns’.
No wonder it won Book of the Year in the 2018 National Book Awards.
It’s difficult to avoid technical terms in such a book, so the author offers helpful footnotes –
I’ll help you out with the medical terminology and provide a bit of context about what each job involved. Unlike being a junior doctor, I won’t just drop you in the deep end and expect you to know exactly what you’re doing.
The footnotes themselves are often hilarious.
Diathermy is essentially a soldering iron – it heats up the area you touch it on and stops small blood vessels from bleeding by sealing them off. It is important not to clean the skin with alcohol-based antiseptic before the operation, otherwise diathermy sparks can set the patient on fire.
Swabs (used in surgery) are designed with a radio-opaque thread running through them as a marker, which shows up on X-rays as a line. A bit unimaginative – I’d have gone for a radio-opaque ‘WHOOPS!’
But I think my favourite one is:
I once put another of these standard dementia questions to a man in his nineties – ‘Spell WORLD backwards’. He paused and said, ‘As in “the planet” or “the past participle of ‘to whirl'”?’
Having spent years delivering babies myself as well as caring for the very sick and small ones, many of Kay’s obstetric stories rang bells for me personally. And I was moved by the care and empathy that this young doctor felt, that had him sneaking back to check patients were OK, or weeping for an hour when things went wrong. What a shame that this sensitivity cost him too dearly to remain on the giving end. We needs practitioners who really care.
Medicine’s loss is the entertainment industry’s gain. Adam Kay has gone on to become an award-winning comedian and writer for TV and film. Indeed he’s actually performing in the Edinburgh Fringe this year! But his book conveys in the best way I’ve ever seen the pain and the joy of working alongside disease, despair and death. And finding the humour and words and humility to share the emotional costs. It’s already been a No 1 best-seller, attracted over 6,500 reviews on Amazon. I devoutly hope it’s on the essential reading list for the new Secretary of State/Cabinet Secretary for Health and Social Care/Welfare. Changes have been made since Adam Kay was practising, but not enough. Not nearly enough.
NHS successes and failures
Last week I had yet another full examination by a consultant as part of my follow-up cancer care. Meticulous head to toe inspection. I’m overwhelmed by the efficiency, skill and compassion I’ve experienced at first hand in the years since I had the primary tumour removed. It could not be bettered.
And who could fail to be awed by the detailed reporting by the BBC this week of the Pakistani conjoined twins, Safa and Marwa Ullah. Two years old and recently separated.
Vast teams of top ranking practitioners working to give those two little girls as good a future as possible. The sight of the grateful mother, a widow with seven other children, kissing the hands of the surgeons said it all.
But I’ve also seen things go pear-shaped – for relatives and friends as well as those I’ve read about. 
And according to the media, a new publication, the NHS Resolution report, provides a worrying picture of the rise in claims for compensation. In England alone, in 2018-19,10,678 new claims were made for clinical negligence. The costs in payouts increased by £137 million to almost £2.4 billion! (NB. this includes legal costs not just the money paid to the claimants.) Mind blowing statistics, aren’t they? Furthermore some 10% of those claims related to perceived deficiencies in maternity care but, because these are extra costly, they represent a disproportionately high percentage of the total costs.
As the CEO of the Medical Defence Union said, this amount of money could have funded over 15 million MRI scans or 112,000 liver transplants. What a sobering reality check.
I feel a mixture of emotions: regret for those people whose care has fallen short certainly but also anxiety for those whose practice is called into question as well as for the NHS as a whole. Every example of negligence exacts a toll from the patients and families concerned. But the spiralling costs of compensating dissatisfied clients affects us all. Our world renowned health care system is buckling under the strain. Something has to give.
One of my ongoing files for a possible future novel is labelled RESOURCE ISSUES. My life-long aversion/allergy to numbers has kept it low down in the pile, but it might yet become a front runner if this state of affairs continues to escalate.
The miracles of modern medicine
Two days ago I experienced a miracle at first hand. Please indulge me this week if this post is entirely personal.
For the past six months my heart has been chaotic. In physical rather than medical terms I’ve been dizzy, sick, fainting, tired beyond belief, dependent on powerful medication to give even a pretence at normal functioning.
Two days ago I was lying in a special lab/theatre watching a rather shy, self-effacing man (known in the medical world as a consultant electrophysiologist) thread a catheter directly into that said heart, fire things at it, burn bits of it, provoke it in mysterious ways, and then calmly tell me he had successfully treated the malfunctions. Yep, there and then.
Here’s the written evidence in his own hand:
Six hours later I WALKED out of the hospital at night unaided (yes, of course, with medical approval!). Three days of recuperation and I should be back to my original self – but hopefully wiser, more appreciative, more tolerant … well, miracles do happen! The only slight caveat is the heart might just have been stunned into silence and not actually cured, but that we should know within two weeks.
Words can’t express my personal gratitude for this transformation, but let’s hear it for our brilliant NHS and all who play a part within it. I met with nothing but kindness, professionalism, friendliness and support at all levels in a clean and well-ordered hospital. God bless them all.
Off now for the prescribed ‘rest’ surrounded by the evidence of huge support from family and friends. Thank you all more than I can say. I am officially off the worry list.
PS. For those who have a highly developed curiosity gene or are interested in all things medical, you can watch a video of what an ablation involves here.