It seems as though I’ve seen a lot of people dying recently. Dying as a verb – breath gasping, limbs seizing, guts retching; dying as a noun – interrupted, ventilated, brain dead. After all this time in hospitals – the medical student in the corner witnessing silentlyish the tragicomic human mess – I wonder what I’ll feel when it’s me or my loved ones. Will I feel it for real, or will it seem second-hand, as if I’m remembering something I saw once in a film?
Yep, I’ll admit it. Part of the reason I’d been looking forward to my GP placement is that GPs sit down all day, right? And they start late and finish about 4 o’clock, right? And they drink loads and loads of tea.
I’m halfway through the placement now, and the day goes something like this.
Wake up, jump on bike, arrive at GP, weave through epic crowd of patients, walking sticks, pushchairs etc in waiting room, hoping that none of them are already on the lookout for me. Find consulting room, log onto computer, find GP supervisor, scan first patient’s records, call in first patient, listen to description of sore back/palpitations/cough/noisy neighbours/insomnia/incontinence/unemployment/divorce/pregnancy/itchy toe, ask semi-informed questions relating to symptoms, rack brains to check for obvious missed things, smile, examine back/chest/abdomen/toe, write in notes, ask about ideas concerns and expectations, check BNF, discuss options, ask questions, explain medications, call doctor, present history, write in notes. See next patient, do neurological exam, explain difference between tension headache and migraine, try to allay anxieties about medication side effects, calculate BMI, check appointment list, apologise to next patient for lateness, listen to chest, look at tonsils, take temperature, print diet advice, call the doctor, breathe. Feel a pulse, take patient for ECG, diagnose atrial fibrillation, discuss management with doctor, explain different anticoagulants to patient while doctor writes referral, pass tissues, make small talk about patient’s son who is training to be a doctor. Think about that cup of coffee. Join doctor on home visit, take blood pressure, write in notes, play with the dog. Drive back to surgery, grab lunch, mainline coffee just because I finally can. Return to consulting room, call in next patient, repeat.
The thing is, I was looking forward to this placement a lot; I always thought I’d like GP and I was interested to see how the days would be. I like people’s stories. I like that every patient has a social or psychological side to their presentation, and that that stuff matters to the GP. I like that I have responsibility here – my own list of patients each day who I see on my own. I like that when I say I’m the student doctor people actually nod and stay in the room, and even listen to what I say. I didn’t realise how crazy busy it would be though. I take my hat off to GPs. The job is phenomenally grinding and complex and they work their socks off. I don’t know if I could do it forever, I don’t know if I have it in me to care enough, in ten-minute slots, about every sore foot and infected finger and sleepless night that walks through the door, and then to be on-the-ball enough to pick out the cardiac arrhythmia, the sick baby, the case of cancer and do something in time. It remains to be seen if I can do that.
The thing is though… here’s the thing: when I get home each night, and stop to think about it, I have had an awesome day.
“Is that physio coming back today?”, asks Mrs Jones in bed three. “The dishy one? Oooh, he was so tall and dark. The most handsome young man you’ve ever seen.”
Mrs Jones is 91. “This is one of the many great things about geriatrics”, laughs the consultant. “You don’t hear this stuff anywhere else.”
I’m doing a three-week ‘career experience’ in geriatrics, and it’s great. It’s one of the fairly few specialities where you have to be a real generalist – old people come into hospital for lots of different, often interconnected, reasons. Perhaps they come to A&E because they’ve fallen over at home and broken their hip, but the geriatrician’s job is to work out why they fell and try to treat the cause. Did they have an arrhythmia, an abnormal heart rhythm? Does their blood pressure drop too much when they stand up? Are they unsteady on their feet because of cerebrovascular disease or Parkinson’s or arthritis? Do their medications need adjusting? Or is it just that they can’t see properly and their house is a bit cluttered? I love detective stories, so this kind of medical sleuthing really appeals.
It also takes more than just doctors to do the job. There’s no point in fixing Mrs Jones’s broken hip if there isn’t also a dishy physio to help her learn to walk again, an occupational therapist to make sure she can manage at home and a social services team to arrange carers to come and see her. And you have to care about people’s whole lives, not just their illness. What kind of house does Mrs Jones live in? Are there stairs? How many? Where? Who is at home with her? Does she have a husband who can help, or is she the one looking after him?
People say geriatrics must be depressing because your patients are old and so many of them will die. I don’t really see it like that though. We will all die, but these are people to whom small things make a huge and immediate difference. Like Mrs O, age 89, who cried with happiness the first time she walked again after her hip operation. Or Mr H who didn’t mind being in a residential home as long as it was close to his friends. We seem to fail so often in this country, in the way we treat our elderly. We need to get these things right – our parents and grandparents deserve this.
Of course there are sad things. My constant lament – that people come into hospital with some minor ailment and end up diagnosed with something worse – is ever present here. Like Mrs B, who complained of constipation and ended up with metastatic cancer.
And it is ethically fascinating. As my consultant says, “You can’t get as far as breakfast in our society without having to make dozens of ethical decisions.” And geriatrics is the same. Geriatricians decide on a daily basis whether patients can give informed consent for a treatment; when a procedure is in someone’s best interests; when it’s ethically right to withdraw active treatment and allow someone to die.
Mrs Brown is 95. She came in several weeks ago after a fall in her nursing home, and then developed pneumonia. She is frail and sick, and has dementia, and her family want her to be allowed to die peacefully without any more aggressive treatment. My consultant agrees, but for some reason she has been started on antibiotics anyway.
Mrs Brown has fallen to one side in her hospital bed, tiny against the pillows. A bag of antibiotics hangs from a drip stand by her bed, snaking into a cannula in her hand. My consultant tries to rouse her but she doesn’t speak, just grips his hand in both of hers and doesn’t let go. “It’s frustrating”, he says. “What benefit are we giving her with these antibiotics? Take them down. Take the cannula out.” He turns back to Mrs Brown and squeezes her hands. “Are you alright? Is there anything I can get you?” She opens her eyes for the first time and smiles. “Can I have a nice cup of tea?”
Doha to Phnom Penh. We take off in the witching hour, planes waiting on the dark desert tarmac like strange sea creatures. Does anyone ever actually stop in Doha? Second flights always feel like no-man’s land to me: between two unknowns, a stranger to everyone. And night flights, as everyone knows, are the ones that vanish. From an unknown to a mystery.
Anyway, by the second flight I’m often too tired to care. And this one’s half empty, so I manage to lie down and sleep for a while.
I’m woken by a loud thump. To my mind, thumps on planes always = imminent death. Looking round however, I realise that a man has collapsed in the aisle behind me. There are a host of, well, hostesses around him and he’s just starting to move again – looks like he fainted. He’s ok, I think, lying back down to sleep. Also, plane still in air – phew.
That’s when I hear the announcement. You know, the announcement. “Is there a doctor or a nurse on the plane? Can any doctor or nurse please come quickly.”
Me? Naaaah, I think, looking round. There has to be a doctor or nurse on this huge plane somewhere. They’re pretty common professions. Several doctorless and nurseless seconds go by though, and I find myself standing up. I thought this moment would terrify me, but it doesn’t. (I’d be more terrified if I wasn’t pretty sure the guy has only fainted).
“I’m not a doctor” I say, going over to the huddle of hostesses. “But I’m a student doctor”.
They turn. “Oh, thank you doctor”. (Did they hear me?) A case appears containing a handheld sphygmomanometer and a shrink-wrapped stethoscope. Can you check his pulse and blood pressure for us, and write a doctor’s report?
Can I? Well, this is what I’m training for. I put the cuff round his arm, so grateful for those lessons, way back in first year, on how to measure blood pressure by hand with a stethoscope. It’s a surreal moment, listening for the Korotkoff sounds over the roar of jet engines. I take a quick history too, checking there’s nothing else going on.
I’m lucky, the guy is ok and I’m confident to write that down (stating clearly my student status). Returning to my seat, I realise it’s the first time I’ve had to use my skills – however basic – in a real situation, far away from guidance. It feels good.
There are hundreds of medical mnemonics out there to help poor hapless students remember their facts. I just found this photo illustrating one to help you remember the types of thyroid cancer: Please Feed My Alligator (papillary, follicular, medullary, anaplastic). Anaplastic tumours are the worst (and also closest to the alligator’s mouth). The picture also happens to illustrate brilliantly how I feel about my exam tomorrow.
While we’re at it, I found another excellent mnemonic the other day about catching cats as a way of remembering the Glasgow Coma Scale (‘decorticate’ sounds like ‘caught a cat’, which you’d do with flexed arms… oh never mind). It made my day anyway.
Exams are back. Or, we’re back at exams. There are a few distinct species of medical student who emerge at this time of year. Here’s your handy guide to recognising them:
The super-competitive one.
Says: “I was in the library ’til 1am last night, then my housemates and I went through all the Parkinson’s plus syndromes before practicing the hip, knee and elbow examinations. Do you know the chemotherapy regimens for myeloma? They’re easy, I did them this morning.”
Found: on the ward or in the common room, discussing rare syndromes with other members of same species. Usually wears shirt, ID badge, stethoscope and smug smile.
The self-depreciating panicker.
Says: “Oh my god, I’m definitely going to fail. I spent all of yesterday looking at cardiology and I can’t remember ANYTHING!”
Found: in the library, semi-visible behind huge pile of books, notes, highlighters and can of energy drink. Wears stressed expression.
The overly nonchalant one.
Says: “Oh yah, whatever, I never do that much revision. I was playing rugby/trampolining/running a half marathon yesterday. I got 82% last year though.”
Found: having a coffee and chatting loudly at table next to self-depreciating panicker.
Note: no matter which species you identify with, or even if – god forbid – you think you’re normal, it is never ok to adopt either an a) non-competitive or b) contented demeanour. Think revision sucks but you’ll probably be ok? Nope, no way. It’s just not said.
Me? Well, I’ve clearly developed a fetish for post-it notes and have pink and green spots swimming in front of my eyes. Now, what’s that syndrome called again?
There are some things in medicine you’d think it’d be quite important to get right. To have good technique and know what you’re doing. For, you know, everyone’s sake.
Doctor: “So, what do you want to get out of this clinic today?”
Me [uncharacteristically prepared]: “Well I’d like to understand the basic management of some of the common urological presentations, like haematuria and prostate cancer. And I’ve never done a PR, so I’d like to learn how to do that if possible.”
Doctor: “Great! We’ll see what we can do.”
Half an hour later, in walks Mr Unsuspecting Prostate.
Doctor: “I’d like to examine your prostate if that’s alright”.
Mr P: “That’s fine, doctor”.
Doctor: “And we have a medical student here today. Do you mind if she examines your prostate as well?”
He sits back down at his desk, leaving me standing there with a glove, a sachet of lube and a patient in front of me in the foetal position. I think this is most awkward I’ve felt since coming to med school. I guess I thought there might be some…instruction. I’m aware that if I ask what to do it might make Mr P feel more uncomfortable. And yet if I don’t, I might as well be any old person off the street who just happened to find a glove, some KY jelly and an interesting opportunity.
Oh well, perhaps that line was crossed a while ago. Anyway, I should know. How hard can it be?
I sigh, choose a finger, and go for it.
Have you ever started a sentence and realised you have absolutely no idea where it’s going?
Yesterday I found myself sitting in the Dean’s office, in the biggest university hospital in the capital of Ethiopia. Huge, shiny table. Award certificates. Business card holders. The Dean is a thoracic surgeon, for Chrissake. Very Good English.
“So, what can I do for you?”
Did I mention that this trip was somewhat fly-by-the-seat-of-my-pants? I suddenly feel a wave of guilt at my own audacity, that I thought I could just walk into this hospital because I’m a medical student and I felt like it. I can feel myself blushing. Deep breath. I got this far, I think. Don’t be intimidated by a shiny table.
I tell him who I am, some approximation of why I’m here. I can hear myself as if from outside. Am I being completely ridiculous?
“So I hoped it would be possible to spend some time in the internal medicine department.”
He looks at me for a long moment.
“Of course! Welcome. Anything you need, just let me know.”
I breathe again, grin, and shake his hand. I often have a suspicion that much of medicine is about bullshit. This is just practice, right?
The patient has a congenital heart defect, which means that when it comes to cardiology clinics he’s seen it all before. In stark and somewhat hilarious contrast to me.
The consultant hands me the ECG. “What do you make of this?”
“Um, well… there might be some right bundle branch block”.
This invites a glare. “What do you mean, there might be some bundle branch block? What year are you?”
He turns to the patient on the bed. “Alright if this student listens to your chest?”
“You might learn something interesting”. This is aimed at me, clearly. I pull out my stethoscope and start to listen.
“No, never do that! If I saw you doing that in an exam I’d fail you immediately! Do it like this.”
I replace the stethoscope, feel for the carotid pulse and listen again, until I’m distracted by an unexpected sound.
“Well, have you heard it yet?”
“Er, no… because the patient’s laughing.”
The consultant spins round. “What are you laughing at?”
“Oh, sorry. Sorry. It’s just that I’m a student too, so I know what it’s like to get shouted at.” The patient is trying to suppress a smirk. Unsuccessfully. “I’m just glad it’s being aimed at someone else for a change.”
I walk into the A&E cubicle and draw the curtain. An elderly man lies propped up on the trolley, all toothless smile and ruddy cheeks. He has a hook on his left arm that’d put the fear of god into Peter Pan.
“Hello sir, I’m one of the medical students. Would you mind me asking some questions about what happened tonight?”
“Oh, no love, fire away! I’ve been having this cough for a while is all. Then I went to the doctor today and he said I have water on me lung.”
“Have you been having any other symptoms with the cough?”
One of my favourite things about this particular hospital is the way half the patients sound like characters from The Archers.
“Oh no love. I was out driving me tractor this morning.”
One of my least favourite things is the way hospital turns perfectly normal, cheerful individuals into part of an institution. The next morning I go to the respiratory ward and find Mr Archer lying in bed in a gown, his hook resting to one side, his smile rather less wide.
“Hello love, look at all the stuff they took out of me.”
He has a chest drain in – a tube snaking from his pleural cavity between his ribs and down into a plastic bucket on the floor.
“Two litres came out in five minutes that did, it felt ever so strange. I was walking around with all that and never knew!”
I hope Mr Archer is ok. I really don’t want him to be just another old man who walked cheerfully into hospital with a cough and came out with cancer. Those stories are all too frequent and too sad. I wonder whether I think about it too much, whether I ascribe sadness to people in hospital who are really feeling fine. But I can’t help seeing the wards full of blank faces, all identical in hospital gowns, and knowing that a few days ago they came into A&E as individuals, walking and smiling perhaps, just with a cough.
So I’ll go back on Monday and see Mr Archer’s test results. I want to discover that his pleural effusion was caused by jumping down from his tractor too fast, or being too exuberant with his hook. I don’t want to find any cancer, any heart disease, any pneumonia. I want a happy story please.