In her controversial new book, Rachel Clarke describes the thrill of saving lives in a frontline NHS hospital – and exposes the working conditions that almost broke her
Nothing quite matches the exaltation of knowing, without doubt, that for the first time you have saved somebody’s life.
It was the end of a gruelling weekend on call. Sunday night, approaching nine o’clock, the start of evening handover and liberty. Tessa, my fellow house officer, and I had just spent 45 of the preceding 72 hours responsible for the clinical needs of several hundred medical inpatients. We were exhausted and desperate for it to end.
As I worked my way through my last few jobs on the ward, impatient to be free, Tessa bleeped me from another ward.
“Rach, can you come and have a look at this guy? He’s got pneumonia and I’ve started him on antibiotics, but there’s something that doesn’t look right.”
Tessa had been asked to review Mr Brewer, a man in his sixties with a new diagnosis of bowel cancer, on account of his fever and mildly low oxygen levels. When she listened to his chest, the telltale crackles at the base of one lung clinched a clinical diagnosis of pneumonia, for which she had prescribed antibiotics. Writing up her entry in his notes and looking forward to her post-on-call beer, she had noticed a change in the sound of his breathing. Brewer had just returned to his bed from the toilet. Previously comfortable, he now looked distressed and pale. He denied any pain in his chest and, when she listened with her stethoscope, nothing had changed. He just looked … wrong.
I worked my way through the “A, B, C” protocol that should frame every doctor’s emergency assessment.
I knew that “A”, his airway, was not blocked since he could whisper, albeit almost inaudibly. I ignored, for now, the poignancy of his words, coming from a man who looked as if he was dying and, worse, wore the dread of someone who knew it. “Please … tell my … wife … not … to worry … about me.” I had to stay hard. There was no time to be distracted by sentiment.
“B”, his breathing, was horrendous. Brewer’s chest had the wet rasp of a patient who is drowning in his own bodily fluid. His lungs were flooded.
“C”, circulation, was no better. His hands were clammy. Where the pulse in his wrist should be, I could feel nothing. His blood pressure must have crashed.
In spite of his feeling no pain in his chest, I was certain he had suffered a massive heart attack while he had been away in the toilet.
As the nurses arrived, I asked one of them to run for intravenous morphine and diuretics that would take the fluid off his lungs and heart. Without them, his heart would remain unable to beat properly and a cardiac arrest was inevitable. The nurse refused.
“He’s got no blood pressure. If you give him those drugs, you’re going to kill him,” the nurse said. “There’s no way I’m giving them.”
Brewer’s lungs were now so overloaded with fluid that blood-tinged foam had started frothing from his lips and he was slipping into unconsciousness. I – or, rather, he – had only seconds. Self-doubt couldn’t come into it. And so, almost snarling – the pressure felt so fierce – I shouted, “Get me the drugs! Now! I’ll give them myself.”
It wasn’t professional, it wasn’t polite, but every intuition I possessed screamed at me to give the drugs. If I was wrong, my actions were probably going to kill him.
I pushed 10mg of morphine into Brewer’s vein. For a second, nothing. Then, as we stared, the blue-grey mask of imminent death started to blossom into healthy, pink flesh as blood suffused his oxygen-starved tissues. It felt as if we had raised the dead, brought about a resurrection.
I’d love to pretend that Tessa and I reflected wisely on this experience, but we couldn’t stop beaming. We felt like real doctors at last – decisive, brave, just like the white-coated heroes on TV. Later, drunk on euphoria and vodka, we sat up half the night, reliving it. We felt – in our naivety – invincible. For one night, in our minds we ruled the hospital.
No one was the slightest bit interested in our grumbling. In their day as junior doctors, went the consultants’ mantra, it was much worse – we didn’t know how lucky we were not to be working the 120-hour weeks of old.
Perhaps. But the old days had at least had proper teams of doctors, a traditional surgical “firm”, led by a consultant who kept the same set of juniors for six months or more. We were mere shift workers, numbers on a spreadsheet who slotted in and out of days and nights on the roster almost as interchangeably as the patients. No one knew us, let alone formed a meaningful relationship with us.
Left, by and large, to our own devices, we would race through our jobs at breakneck speed to try to stop them overwhelming us. We could just about survive 15 hours of nonstop work, but, when the end of a “normal” working day started nudging midnight, our judgment became blurred. Sometimes, towards the end of a shift, I felt so drunk with fatigue I could barely pronounce my name, let alone feel confident with patients’ lives in my hands.
Only rarely was a patient’s outcome in my control. Usually, getting something done meant managing and sometimes deliberately circumventing arcane systems that often seemed designed to waste our time and thwart good patient care. Hospital computer systems that were unfit for purpose; scan results that were accessible only to a team that was so understaffed you could have whipped out an appendix in the time it took someone to get back to you. Sometimes, I felt less like a doctor than a paper-pushing, clipboard-carrying, largely ineffectual secretary.
With one patient, my persistence became an obsession. Major Robert Ashdown was a retired army officer. He had awoken that morning in crippling abdominal pain. Now, my examination revealed a classic “acute abdomen” – tender to touch and protected by rigid abdominal muscles, a clue that blood or infection was irritating his abdominal cavity. Through gritted teeth, he exhaled as I pressed gently down on his belly. Anyone else would have screamed. It felt like palpating hardwood.
Eventually, with a diagnosis still elusive, my consultant had no choice but to take him to theatre. The surgery revealed a gastric cancer, hidden beneath a huge blood clot. There was nothing to do but pack the abdomen tightly with gauze and stitch it back up again, temporarily staunching the bleeding, then keep Ashdown comfortable until it inevitably restarted.
There was something uniquely horrible about the situation. Ashdown confronted the fact that, at an unspecified time in the next two or three days, he would begin to bleed from his tumour and, when it started, he would haemorrhage to death.
“Where would you like to be?” I asked him.
Our local hospice was renowned for the excellence of its drinks trolley. Ashdown was trapped on a frenetic surgical ward. What he longed for, in his final days, was somewhere calm where he could be with his family. There was one problem. Beds in the hospice were like gold dust. To earn one, you needed symptoms that were too difficult for GPs or hospital wards to manage. Ashdown was entirely asymptomatic. Yet he faced certain death in just a day or so.
The next morning, in between the thousand other jobs, I made calls to the hospice. The ward nurse sympathised, but said he wouldn’t meet the criteria. After begging, she agreed to pass me on to the ward doctor. Same conversation, same scepticism, but a reluctant agreement to let me speak to her senior registrar.
By now it was late afternoon. I wished I had never said anything to Ashdown. His family were ecstatic at the idea of the hospice bed it was not in my power to give.
A tense conversation with the hospice registrar ensued. It was a no. Finally, she agreed to let me speak to her consultant.
“I know that on one level he meets none of the criteria,” I said. “But he’s living with the knowledge that, at any moment, bleeding will begin that will be the certain death of him.”
There was a long pause. Then the consultant told me a bed had unexpectedly become available in the hospice. I put down the phone and slowly exhaled.
Sometimes when a man – in particular a military man whose whole being radiates strength and composure – breaks down and cries it can feel embarrassing. But, on this occasion, we all wept freely. I later learnt he had died two days later, surrounded by his family, overlooking the hospice garden.
It had been a long night. Normally, stamping on one of the cockroaches that invaded the hospital corridors under the cover of darkness was a particular perk of my night shifts. Infection control was everyone’s job, after all.
But it was nearly 8am, my shift was almost over, and I felt too bombed out to derive any pleasure from dispatching pests to cockroach heaven.
Studies show that the fatigue levels experienced by doctors at the end of busy night shifts can impair their mental acuity more effectively than exceeding the alcohol limit for driving. So, if you become unwell in hospital at the wrong moment, you might find your life rests in the hands of someone who is essentially drunk. Right now, I didn’t just feel inebriated. I felt as if I were face down, drooling into the bedroom carpet, having partied all night, too tired to drag myself up onto the mattress. I was still putting one foot in front of the other, walking doggedly to the next ward that had bleeped me, but my feet just didn’t seem connected to the rest of me.
Now, so close to the end of a particularly grim night on the Surgical Emergency Unit – a workload for two being perilously managed by one – I made the fatal mistake of starting to dream ahead to the end of the shift. Coffee, bacon sandwich, a hot shower. Such indulgence is always punished by a ghastly emergency. On this occasion, it was a fast bleep. Rarely used by the nursing staff, this means they are so worried by a patient that they ask switchboard to summon you urgently by name, a whisker below putting out a crash call. Unlike the crash call, when a resuscitation team arrives at the bedside, a fast bleep is received by only one doctor – he or she alone is responsible for handling the emergency.
A few months into my life as a doctor, this was my first fast bleep. A disembodied voice hissed out of my pager: “Dr Clarke to the Surgical Emergency Unit immediately.”
In the space of a second, I went from soporific stupor to wide-eyed hypervigilance. I found myself sprinting, heart pounding.
The nurses had already swung into action.
“Bay 5,” someone called as I burst through the swing doors. “It’s a big upper GI bleed.”
Major bleeding – haemorrhage – is one of the swiftest and messiest routes to oblivion. A particularly distressing kind of bleeding for both patients and staff is that which arises from the upper gastrointestinal tract: the mouth, the stomach and the tube that connects them, the oesophagus. If an upper GI bleed is too rapid the patient ends up vomiting up their own blood uncontrollably.
As for many patients with a history of chronic alcohol abuse, years of drinking had scarred Jennifer’s liver into a shrivelled, fibrous husk though which blood struggled to flow. This put her at risk from bleeding elsewhere – in particular the engorged veins of her oesophagus. Shortly before 8am that day, one of those overstretched veins had finally burst.
She was lying, looking ashen, drenched in her own fresh blood. It was everywhere. Her face, her gown, the curtains, the sheets. No one ever tells you how cloying the smell of large quantities of blood can be. It was like being inside a butcher’s shop.
Already, her blood pressure had fallen so precipitously she was beginning to lose consciousness. We had very little time. The nurses had grabbed the kit for placing the biggest cannulas possible in her veins and my job was to site them. As I tied my tourniquet as tightly as I could manage, I asked someone to run for O negative blood and bags of fluid. If her blood pressure continued to plummet, she would have a cardiac arrest. There was no time for fumbling. My registrar arrived just as I’d managed to access the veins, and we were forcibly squeezing bags of blood into our now unconscious patient. An old pro who’d seen everything a thousand times before, he calmly took her to theatre, where his expert hands would attempt to save her life.
As Jennifer was wheeled away, she left a bedshaped gap on the floor, bordered by the bloody chaos of our footprints. Barely ten minutes had passed, my patient was gone, my shift, abruptly, had ended. I noticed I had blood in my hair. I peeled off my blood-soaked scrubs and stood under the shower, as though water could wash the night away.
The UK is facing a terrible haemorrhage. Doctors are leaving the NHS in droves. England, Wales and Northern Ireland are short of more than 23,000 nurses, 6,000 doctors and 3,500 midwives. The lifeblood of the health service is rapidly draining away.
The Department of Health press office response is to whip out statistics to show how well staffed the NHS is. The secretary of state for health, Jeremy Hunt, likes to talk, for example, about the “10,000 additional doctors” since 2010. But those 10,000 doctors shrink to half that when part-time doctors are factored into the mix and, once the UK’s rising population is taken into account, there is no increase in doctors per head of population at all.
Britain has fewer doctors per capita than almost any other country in Europe, including Bulgaria, Estonia and Latvia.
Doctors are people-pleasers, not revolutionaries. When the rebels among our schoolmates went behind the bike sheds, we went to the library. Then, after choosing six years’ worth of exams at medical school, we accepted working conditions that in any other profession would be met with incredulity. I’ve worked in a hospital whose doctors’ mess was infested with rats and cockroaches.
We used to take this kind of treatment. But in 2016 when Hunt, sought to impose a new contract on junior doctors, he achieved something unprecedented. He politicised junior doctors, turning us en masse from compliant NHS rota fodder into accidental militants.
At home, my husband and children took a dim view of any new-found “militancy”. I started setting my alarm half an hour early to respond on Twitter to the latest government spin before getting the children to breakfast club and myself to work. At one point I organised a protest outside Hunt’s office. That night, Dragon Lonsdale, another junior doctor, and I crawled into our sleeping bags, conscious of the sheer absurdity of two doctors, both parents with young children, sleeping rough to try to persuade a cabinet minister to talk to a trade union.
It was fear, fundamentally, that stoked much of the anger. Not fear of losing out financially – although the idea of being paid less for our work was clearly inflammatory – but of being forced to work longer and harder than we already did, of being stretched even more thinly. I knew my limits. More than anything, I feared being driven out of the job I loved by intolerable increases in my workload.
We knew we were barely delivering a safe five-day service and yet, in Hunt’s parallel universe, we now had to provide a seven-day one. In the absence of additional doctors, the only ways to deliver new weekend services would be for our overall hours to increase, or for us to be removed from our patients from Monday to Friday in order to beef up the weekend workforce.
I was called one night to cannulate a patient at my 4am nadir. He was in his fifties. Well enough to twinkle with delight at the arrival of the female house officer. I should have noticed that his smile was more of a leer. But I was exhausted. Crouching down, with the curtains closed around me and the ward in darkness, I was oblivious to everything but the veins I scrutinised. A hand suddenly gripped mine. “I bet you like being down there, don’t you? On your knees in front of me?” I realised his other hand was rubbing his genitals. Had it not been 4am, I like to believe I would have torn strips off him. I told no one, cried briefly, felt grubby and moved on.
Although this is exceptionally unusual behaviour from a ward-based inpatient, in the cut and thrust of the emergency department, we are steeled for abuse. I’ve seen doctors spat at for the colour of their skin, nurses assaulted. Before my first stint in emergency medicine, I ran into a friend, just as she finished an A&E night shift. “I just wish,” she said, “that I could get through one shift in this place without a member of the public calling me a c***.”
The moment my own “keeno lifesaver light” went out was at 10pm one evening. A long shift was over. Because we were a doctor down on our ward – and had been for many months – I’d been fighting fire since 9am just to keep on top of all the ward jobs. Now, I felt tired and angry.
That morning, one of my favourite patients, a softly spoken Scot in his seventies, was desperate for a chat. I promised him I would come later. Callum’s case had touched us all. A virulent skin infection had spread into his bloodstream, causing his kidneys to fail permanently. Within days, he had gone from being active to requiring renal dialysis three times a week. No matter how overstretched I was, I always eked out time to chat with him.
That night, though, my ability to give had run dry. All day, I’d been too busy to sit with Callum, as I had promised him I would. Every time I scuttled past the open door to his room, he called out, eager to chat. “Come on, Doc. When are you going to sit down?”
Head down, too embarrassed to meet his eye, I felt the anger that had been brewing inside me all day finding a wholly undeserving target. It felt as though the beginnings of callousness – that first twisted step towards the cruelties seen at Mid Staffs in the mid-Noughties – might be perverting the doctor I had aspired to be. I hovered, torn between letting down a patient, having the chat I had promised him I would. But I was paranoid that, if I arrived home that night even later than I was already, our babysitter might be pushed by my erratic hours that bit closer towards quitting. So I slunk away, avoiding Callum’s room, dragging my heels with shame.
When I began life as a doctor, I would freewheel down the hill towards the hospital with a grin on my face. I brimmed with pride. Not merely at being a doctor but being an NHS doctor. Now, it seemed that the system in which I worked had finally soured the love I felt for medicine, for the NHS and – above all – for my patients.
Rachel Clarke gave up medicine for six months last year. She returned to the profession in February 2017 to work as a doctor in an NHS specialist palliative care unit in Oxford
Extracted from Your Life in My Hands by Rachel Clarke, which is published by Metro Books on July 13 (£16.99)