give and take

junior doctors put up with a lot, including each other

rest in peace

"Are you sure it's not urethrostomy?"

"I'm sure."

"How do you spell urethrotomy?"


"U - R - E --" *BZZZZZZZ*


*BZZZZZZZ*


*BZZZZZZZ*


'Hey is that the crash--'

I don't have to complete my sentence. Before I know it we're already in the corridor. A flock of nurses all sprinting in the same direction confirms it and based on where they're headed I know exactly who has died. A nurse reaches the door of the side room before me and turns abruptly. Her eyes are wide with panic. 'Does she have a DNAR???' She asks. "No, she doesn't." I say, brushing past her to get to the arrest.

74 year old female, admitted with a blocked right nephrostomy. Nephrostomy exchanged and now draining well. Prolonged hospital stay due to social issues. 
Background of CKD stage 3, type II diabetes, staghorn calculus, bed bound, morbidly obese, chronic lymphoedema and cellulitis, both legs.
Admission complicated by hospital acquired pneumonia, haematemesis, and most recently acute coronary syndrome and heart failure.
Over the last three days, eGFR has dropped from 13 to 9. Persistently hypotensive - systolic of 70 - treatment resistant hyperkalemia: potassium > 6.0 for past 2 days despite multiple dextrose / insulin infusions.
Assessed by renal, cardiology and ITU consultants, deemed not a candidate for dialysis, coronary artery catheterisation or escalation to ITU. DNAR discussed and refused on multiple occasions. For cardiopulmonary resuscitation despite poor prognosis

She had been in hospital for 3 months, suffered two bouts of pneumonia, had bled from her gut and now her heart had become so starved of oxygen that it was struggling to pump blood around her body and to her kidneys, which were slowly shutting down, causing potassium to build up and mess with the electrical activity of the heart.

We were this close to sending her home last week, before we had diagnosed her heart attack, and before her nursing home had decided to shut down, leaving her stranded here.

"She's going to die. You know this, right?" Our reg told us four hours ago in the privacy of the doctor's office. "The only question is when." And yet only an hour ago she was sat up in bed talking to the med reg, shaking his hand, asking if she could go home.

Now, entering the room - it takes me a moment. I know I should spring into action but I hesitate. I stand there, paralysed, trying to make sense of the situation, trying to comprehend the uncanny slackness of her jowl, her mouth agape and eyes like glass, staring past ceiling and into oblivion.

"HAS THE CRASH CALL BEEN MADE. SOMEONE CALL THE CRASH TEAM." Bristol yells and starts chest compressions. "WILL SOMEONE SECURE AN AIRWAY."

His voice snaps me out of it. I squeeze past Bristol to get to the head of the bed and perform a jaw thrust. It's my first time not doing it on a mannequin, but the training kicks in and my hands seem to move on their own, fingers slotting in snugly behind her mandible, palms resting on her temple as if they belong there.

"Can I have a bag valve mask please." I say, and one materializes within seconds. I clamp the mask down onto her face. I struggle to keep her head from rocking wildly as her torso bucks under the force of Bristol's chest compressions. "Is that 30?" I ask.

"Yeah."

Two breaths, watching for the chest to rise.

My mind is all numbers. I don't notice that the other house officers have arrived until one of them swaps with Bristol. All I can register are a pair of hands pumping furiously up and down a dead person's chest.

27... 28... 29... 30...

Pause. two breaths. Not too fast now.

One... Two... and the countdown begins again.

It's incredibly quiet in the room. Dead silent except for the creaking of the bed in time with the laboured breathing of whoever is doing chest compressions. By now, the anaesthetic SHO has arrived, relieving me of the mask and pressing it against the patient's face with undeniably superior technique. The med reg has also arrived and is stood at the foot of the bed, keeping track of how many cycles we're doing, what drugs have been given, what the heart monitor is showing. The on-call house officers take turns doing chest compressions. Fluorescent light envelops the room in stark, unwavering whiteness. There is a palpable discrepancy in the ratio of bodies in the room to the amount of activity taking place. It feels like strangers waiting in line at a bank, attentive and idle. The med reg is the teller, but instead of 'next please' he says 'listen to her chest,' or 'give her a shot of adrenaline.'

The trace shows electrical activity, but neither the anaesthetic SHO nor myself nor the other house officer can feel a pulse. We do another 2 cycles of CPR before stopping. Although there's no pulse she gasps intermittently, laryngeal muscles in visible spasm. "Agonal breathing," The anaesthetic SHO says by way of explanation.

At some point the med reg says "good job everyone," and it's over. "Time of death: 8:03." The crowd disperses and we vacate the room for the nurses to dispose of the detritus and get the body ready. Pattern, the patient's next of kin is already on her way.

The med reg tells me he'll speak to the family and I agree to scribe. When Pattern arrives, she is in tears. She's ushered into the doctor's office, where Bristol, myself and nurse K are present, listening to the med reg telling Pattern that she passed quickly and with very little pain. Pattern is still sobbing, thanking the med reg for being there, thanking the staff for their patience and kindness. "I know... you did your best to do what was right for her. And... I'm glad she's not suffering anymore." Nurse K offers Pattern more tissues and escorts her to the day room.

"I'll get the listing forms." Bristol says to me.

I'm instantly aware of the irony in that remark, and a day later I'll be able to articulate it. Now that the fuss and commotion has died down, we just carry on right where we left off. No ceremony or moment of silence to mark the occasion. To treat a patient's death as the expected interlude between two acts of a play. A minor interruption.

The med reg says to me, "I've certified her and documented the time of death. Thanks for your help." "Thank you so much," I say. "Thank you for coming."

The notes are sat on the windowsill in the doctor's office. It's 8:30 now, three and a half hours since my shift ended.  Out of curiosity, I look to see what he has written -

Pupils fixed and unresponsive to light
No heart sounds on auscultation
No central carotid pulse palpable
No breath sounds on auscultation

Sincere condolences. May her soul rest in peace.

year of the half nelson

retrospectre

I have this tired preset response for whenever someone asks me what I'm doing in hospital after hours - which is most days. It's something along the lines of, 'I live here now' or 'I've got nowhere else to go!' and it started out as a cute little quip, grinning ruefully and bouyed by a gust of bravado, but lately I've gotten tired of saying it. It's become less of a joke and more a statement of fact delivered in a flippant manner - and after a long day, sometimes even the flippancy falters.

Why does it feel like my life can be summarised as what happens within the hospital.

Has split in two and the world has moved on, and I'm taking a different path that's leading further and further away from everything I've known. A current that leads away from KL and old friends' birthdays.

A day off, outside the hospital, feels strange. Feels like re-entering the atmosphere after having been isolated in space - or coming out of a 10 year coma with a tom hanks castaway beard, trying to remember what the word 'normal' used to mean

---

I went into preston last night, the streets were alive, the city's spark had returned. there were returners sauntering through the streets, and a bar filled with freshers, hunched over their drinks, warily scanning the crowd for a friendly face or something familiar. The outdoor terrace decorated with fairy lights, a young man holding a guitar and the group surrounding him, feeling a little unsettled by the new-ness of their surroundings. A few years later they will identify the feeling as homesickness, look back fondly at their initiation into a world bursting with potential and bright futures waiting to be claimed or squandered away.

Panacea

But he wanted to justify himself, so he asked Jesus, "And who is my neighbor?" 

---

Yet I hold this against you: You have forsaken the love you had at first.

---


Yesterday I made the other urology FY1 cry. Or rather, I was there when she cried.

We had both finished a mammoth day - neither of us had sat down for a second or had lunch. It was 6.30pm - an hour and a half after work had officially ended and we were in the doctor's office finishing up jobs. For some reason the phlebs hadn't taken any of the post op bloods we'd requested in the morning, which meant during grand round there were a grand round of dirty looks directed our way, with looming registrars telling us, 'these bloods should have been done.' Protesting, 'We ordered them this morning,' and receiving in reply a stern look that said, 'these bloods should have been done.'

By the time grand round had ended it was 3pm. 'Jon - let's go through the list. It doesn't look like there's much to do.' I had a referral that needed to be made by 5pm, because that's when the consultant leaves hospital, two urgent discharge summaries to write so that well patients can go home and we can free up beds, and now urgent bloods that should have been done in the morning. 'There are four patients in EDU to be seen. Let's go down and clerk them and then you can finish up and update the list.'

I knew what this meant. What the reg wants is for me to see patients with him, stay back late and sort out paperwork and add patients to the list so that he can go home at 5pm. Which is fine - I get it - but it wouldn't kill him to see one or two patients on his own.

'Uh, I actually have this urgent referral to do. You know, for Mrs Y.? I can join you in EDU afterwards.'


'You can do that down in EDU, can't you? Just bleep him down in EDU.'

Or I can do it from here, now and join you in EDU afterwards.

'I need one of you to come with me and clerk patients in EDU.'

Why?

Selfish. This has happened before. Don't do it

And if someone takes your cloak, do not withhold your tunic as well.

'Okay, sure.'

Two hours later I'm in the office updating the list and trying to sort out what to do with this referral I missed because I was assisting with a catheter and was told, 'Whoever is bleeping you, just ignore it. You're busy with a patient.'

And whosoever shall compel thee to go a mile, go with him twain.

After we got the catheter in, I washed my hands and scrambled to the nearest telephone.

'Hello dialysis unit.'

'Hi, it's Jon urology FY1, did Dr. X bleep me by any chance?'

'Oh he was here a while ago, but he's gone now.'

Perfect.


By the time I had gotten to the office it was an hour past quitting time and I was in a pretty foul mood.

I texted the other FY1; hey quick q have you ordered bloods over the weekend for ward patients?

Not yet


Which means I'll have to do it.

I quickly checked to see if the urgent bloods had all been done, and some part of me wanted the answer to be no, wanted something concrete to confront her with, and some cruel part of me was perversely glad to find that one of them had indeed been missed.

Normally I wouldn't have mentioned it at all and sorted it out myself. After all, what's a few more minutes when you've already over-stayed two hours. But I reasoned, if I continue to do this, she will a.) not realise that her responsibility includes checking that bloods have been sent off and checking the results and b.) believe that things will continue to magically sort themselves out even if she does forget to order or check blood results.

Plus, it wasn't the first time this had happened. We divide jobs into outliers and ward. I've pretty much been picking up after her every day for the past four days, making sure bloods have been ordered and adding patients that have been missed off the list.

The lock in the door behind me rattled, and she came in looking drained and older by about 10 years.

'Hey, how's it going?'

'Not too bad, do you know if Mr Z had his bloods done?' I asked, already knowing the answer.

'... I asked Zoe (the medical student) to check and she said the nurse was doing them.'

'Because it says on the system, it's been collected but... that was three hours ago.'

'Oh.'

'So it's not been done.'

'I guess not... I asked Zoe though.'

'Yeah but.'

'The rest of them are definitely done though.'

'Yeah but what about Mr Z?'



'I guess he's not getting bloods today then.'

'... So when the reg asks, why haven't bloods been done - what are you going to say?'

'I asked Zoe and she said... the nurse was doing it.'

'So you're going to say "Zoe told me it was being done?"'

She laughs. 'Are you afraid of the reg?'

'No, I'm not - but I just need you to know that... these bloods have to be done. It's not okay to just leave it undone. Do you understand?'

'Alright well I'll do it later then.'

'No - we can handover to surgeon of the week, or ask one of the nurses to do it. That's not the issue, what I'm saying is that Mr Z had an AKI so he needs bloods for today. Do you understand? You can't just leave assuming that that they're done. You have to check... '

Before I knew it there were tears rolling down her cheek. I had not expected this.

I sat there, unsure how to suddenly switch from lecturing to comforting her.

'Hey, what's the matter?' I said at last, trying to sound like a friend.

'It's nothing,' she said, still sobbing furiously.

'... is there... something at home? Something troubling you?'

She shook her head and dabbed at the tears with her wrist.

'... is it the job?'

She gave a small tentative nod.

'It's like... I can't do everything...'

'... As in, we try our best, but people still expect things to be perfect?'

She nods again.

'Yeah, I know... you'd expect them to understand that - there's just two of us... doing a four person job, and it's not like we're sitting around drinking coffee...'

The tears had nearly stopped now, her gasping reduced to a sniffle.

'And I don't know why they still act like it's reasonable to expect us to get everything done. I mean... either they know it's not possible or...'

And then I stopped speaking. Because I realised that I had been doing to her the exact same thing I resented being done to me. Being held accountable without a fair trial - without considering there might be more to the story - something wrong with the system rather than with the individual. She wasn't incompetent. She had sorted out the urgent echo request and another patient's heparin induced thrombocytopenia screen. To have done both by quitting time is no small feat. She simply hadn't gotten round to checking that all the bloods had been done. She was doing her best - and I had somehow convinced myself that her failure to check on Mr Z's blood was due to negligence or some kind of mental laziness.

And I was reminded of something I had already suspected; that cruelty comes from suffering. And that the kind of registrar who abuses their house officer is the kind of registrar who was abused as a house officer - and becomes the kind of house officer who abuses other house officers, and makes nasty private comments about the ward sister's weight and appearance, and gradually loses the ability to understand anybody's suffering beyond his own, and begins to convince himself that any and every minor inconvenience or mishap is part of some grand conspiracy or deliberate, concerted effort to keep him as miserable as he is now.

'Yeah, but I keep making mistakes... keep missing things out.' She says. 'Like yesterday I prescribed blood for that lady - only to find it hadn't been given... and I had to represcribe it, because apparently you can't prescribe 2 units at the same time...' She shook her head. 'I mean... sometimes it's just like... what's the point?'

'Yeah, I know what you mean. Like all that work is for nothing.'

She nods.

'I think maybe you're just tired. It's been a long week and you're only human. Have you been getting enough sleep?'

'I think so.'

'I don't think so - cause you have to wake up early to drive here, and you've been staying pretty late, haven't you?'

'But so has everybody else.'

'... I think what you need is to have a good rest - just spend some time away from work and come back refreshed. I think a lot of it is just stress. And it messes with your sleep too. You know, when you can't get your mind to switch off? I honestly couldn't sleep at all yesterday.'

And then I told her about my delirium dream that consisted of a consultant trying to explain something very basic to me, and me just not understanding at all, and watching as he became more and more frustrated.

And as we talked she managed a laugh, which manifested as a kind of sharp, brittle sound, which I recognised as being the very same one I made just over a month ago and fighting back tears a week later at someone else's house.

---

Above all, love each other deeply, because love covers over a multitude of sins. 

---

Brothers, if someone is caught in a trespass, you who are spiritual should restore him with a spirit of gentleness. But watch yourself, or you also may be tempted. Carry one another’s burdens, and in this way you will fulfill the Law of Christ.

losing strategy

"Sell everything you own and follow me." is more or less Jesus' response to a rich man who wants to get into heaven. Resignation (sell everything) is one thing, but it is continual (follow me). Temptation is ever present to re-awaken your desire for whatever was given up. It is an infinite struggle. Also faith itself requires infinite scrutiny, or it becomes a lie.

---

And Jesus looking upon him loved him, and said unto him, One thing thou lackest: go, sell whatsoever thou hast, and give to the poor, and thou shalt have treasure in heaven: and come, follow me. But his countenance fell at the saying, and he went away sorrowful: for he was one that had great possessions.

I especially like Mark's account because it mentions that 'Jesus looked at him, and loved him.' That tiny detail makes me read it in a different way.

It's as if Jesus is doing a double take. It's like he's finally found a student who has done the required reading. It's like he's finding fruit in a land full of fake trees. He sees something in the young man - a glimmer of hope, a potential crop. Here's a young punk who turns up every day knocking. The kid has moxie.

So he tells him the truth - but the truth is a father willing to sacrifice his only son, a son sold into slavery, a servant in a foreign land, the head of a prophet on a silver platter and apostles in prison, an angry mob and three men in a furnace, a pair of wrists with holes in them, and Jesus standing in the doorway offering his hand, his eyes gentle and full of mercy, saying, 'leave everything behind and follow me.' Already knowing what the young man's answer will be.

no team in eye

If the foot should say, “Because I am not a hand, I do not belong to the body,” that would not make it any less a part of the body. And if the ear should say, “Because I am not an eye, I do not belong to the body,” that would not make it any less a part of the body. If the whole body were an eye, where would the sense of hearing be? If the whole body were an ear, where would the sense of smell be? 

[...] 

But God has composed the body and has given greater honor to the parts that lacked it, so that there should be no division in the body, but that its members should have mutual concern for one another. If one part suffers, every part suffers with it; if one part is honored, every part rejoices with it.

---

people religious about health, religious about cleanliness - what does 'being religious' mean? adhering stringently to a set of actions and traditions - believing that rituals can save you - doing something obsessively in the belief that it isn't futile

---

When I was in fourth year of medical school a consultant stopped ward round and asked us, 'who is the most important person in the hospital?' We stared back at him blankly. "Is it Mr Najar? (referring to himself) (I've forgotten the consultant's name but he was almost certainly Indian) Is it the hospital administrator?" He gave us a wide and benign grin. "No, it's this person right here," gesturing to the lady who nobody had noticed before then, rendered inconspicuous by her dark green cleaner's uniform. She looked back at him and gave a bashful smile, unused to the attention. Mr Najar smiled back warmly at her. "How are you today?" "Fine, thank you." He turned back to face us. Our faces were so blank you could draw on them.

"If she isn't here, then the ward will be dirty. If the ward is dirty then patients will get sick. If this person doesn't do her job, then all our work here is meaningless. Do you understand?" Our heads nodded dutifully. "That's why I always say hello, good morning. Isn't it much nicer when people say good morning to each other? Good morning Rita!" A passing secretary beamed at him without breaking her stride. "Good morning Mr. Najar." The cleaner loitered in the background with her hands politely clasped behind her back, unsure if she was obliged to stay for the rest of the sermon.

I had forgotten about Mr Najar until now. I don't remember what happened before or what came after on ward round. It's lost in the sea of trivial mornings and medical school routine. I know now, however, with almost 100% certainty that none of us had understood the point he was trying to make. We just chalked it up to another eccentric consultant's production - the fanfare and palaver that performers feel compelled to deliver for a captive audience (who are themselves rarely desirous of it).

Last Thursday, as the ward round was entering the last bay, a tall, tanned Pakistani gentleman clad in a deep blue jumpsuit paused his mopping and stepped aside deftly, holding the door to allow the group through. Neither the registrar, who led the ward round, nor the consultant, who followed second, nor the core trainee, who hurriedly trailed after them, uttered a word of thanks.

Later that day, a nurse and a doctor were in the doctor's office. He was in the middle of writing up a patient's discharge letter. She was being strangely polite. She was a staff nurse, qualified a year ago, but it was her first time being in charge of the ward. It was subtle, but you could tell she felt slightly out of her depth - that the weight of responsibility had caught her a little off balance. "I'm sorry to keep barging in - you lot must hate it, us pecking at you all the time for this and that."

The doctor scratched his head and looked at his screen. "I don't think it's as bad as when you ask us to do something and we just look blankly back at you like... umm. I don't know how to do that--"

"-- I know and we're like, please don't look at us! We don't know what to do either!" They looked at each other and laughed, a genuine expression of relief, the sound of tension dissipating.

The doctor nodded amicably and returned his attention to the screen but continued, "So if it's something we can help with then... you know, it goes both ways doesn't it? At the end of the day, we're all on the same team."

And as they talked, you could sort of tell that the nurse and the doctor were listening to each other now, the way sometimes a member of the human race listens to another.