Your Life In My Hands--a Junior Doctor's Story Read online

  ‘From the very heart of the NHS comes this brilliant insight into the continuing crisis in the health service. Rachel Clarke writes as the accomplished journalist she once was and as the leading junior doctor she now is – writing with humanity and compassion that at times reduced me to tears.’

  Jon Snow, Channel 4 News

  ‘A powerful account of life on the NHS frontline. If only Theresa May and Jeremy Hunt could see the passion behind the people in the NHS, they might stop treating them as the enemy, and understand that without them we don’t have an NHS worth the name.’

  Alastair Campbell

  ‘This compelling real-life tale will leave you wondering: is the erosion of the magnificent National Health Service a reflection of politician ineptitude on a staggering scale, or a Machiavellian plan to turn UK healthcare into yet another for-profit industry?’

  Professor Neena Modi

  President of the Royal College of

  Paediatrics and Public Health

  ‘I absolutely loved it this book. Such an elegant, moving and honest account of life on the frontline. This is mandatory reading for anyone who cares about the NHS. I am very often asked what it’s like to be a junior doctor, and I can now direct people to this book. It’s so refreshing to see someone tell it exactly as it is.’

  Joanna Cannon, author of

  The Trouble with Goats and Sheep

  To my father – whose kindness and dedication

  to his patients I try, every day, to live up to

  Author’s note

  A note on confidentiality. The stories told here are grounded in my clinical experience, but I have changed a great many of the details to ensure that individuals are so disguised as to be unrecognisable. Occasionally, a story may draw upon a composite of different experiences from different times, to ensure the confidentiality of any individual to whom it refers is protected.

  CONTENTS

  TITLE PAGE

  DEDICATION

  AUTHOR’S NOTE

  PROLOGUE

  CHAPTER 1: WORDS

  CHAPTER 2: DEEDS

  CHAPTER 3: EXALTATION

  CHAPTER 4: BRILLIANCE

  CHAPTER 5: KINDNESS

  CHAPTER 6: CALLOUSNESS

  CHAPTER 7: HAEMORRHAGE

  CHAPTER 8: MILITANCY

  CHAPTER 9: OESTROGEN

  CHAPTER 10: RESILIENCE

  CHAPTER 11: INSURRECTION

  CHAPTER 12: WONDER

  CHAPTER 13: CANDOUR

  CHAPTER 14: HAEMOSTASIS

  CHAPTER 15: HOPE

  EPILOGUE

  ACKNOWLEDGEMENTS

  REFERENCES

  COPYRIGHT

  PROLOGUE

  A red dirt road steeped in ruddy dawn light and the faintest mutter of guns. The first refugees, hazy in the distance, slowly bearing down on the town. Women and children leading the retreat, bin bags and mattresses balanced upon heads, babies swaddled tight to adult hips. They crossed a façade of buildings peppered with bullet holes, impassive and mute, looking past us. My cameraman and I couldn’t believe our luck. The juxtaposition of gentle morning light with the ugliness of war – it was television gold, and we knew it.

  Before I became a doctor, I turned people’s lives into films for a living. I was a journalist, producing and directing current-affairs documentaries like this one about the civil war in the Democratic Republic of Congo. It was 2003. The conflict, described by Prime Minister Tony Blair as ‘a scar on the conscience of the world’, had already claimed 5 million lives, most of which were civilian. Bunia, the battered town into which we’d flown a few days earlier, was widely regarded as the heart of the slaughter. Rape and brutalities were commonplace. Only a month before our arrival, five hundred townsfolk had been butchered by militiamen armed with machetes. The town’s makeshift, tented hospital was still filled with amputees, the youngest of whom was seven.

  Even as the pace of the displaced began to quicken, and the rumble of guns grew more insistent, I couldn’t resist keeping the camera rolling. The crowd began to jog and then to scatter. Bedding and possessions were dumped in the dust, children started to wail. Defeated militiamen now joined the civilians, armed with AK-47s, yet in flight and disarray. As the army from which they fled finally burst through the trees, all at once we came under their incoming fire. The air hummed with bullets. We stampeded for the only safe place in town: the United Nations peacekeepers’ compound with six thousand refugees already crammed behind its razor wire.

  Inside the UN building, twenty or so journalists now cowered on a concrete floor as gunfire raged around us. Every grenade made the walls shake. We prayed they didn’t have mortars. I was certain I’d be raped, then cut to pieces. I wished I knew nothing about Bunian militiamen’s preferred modalities of killing. I wondered if the man from Agence France-Presse against whom I was crushed would mind if I held his hand for a moment. I longed to call my parents to tell them that I loved them. Our cameras never stopped rolling.

  After four interminable hours, the gunfire finally abated. Casualties now besieged the town’s rudimentary hospital. The UN’s tented city had swollen by another few hundred refugees. We’d gratefully escaped our concrete bunker but, with night falling and distant guns still rumbling, we had absolutely nowhere safe to go. Every street in town was overrun with militia, so we begged the protection of UN peacekeepers’ guns. I lay all night on a plastic sheet beneath the compound’s walls, clutching my mosquito net, too scared to close my eyes. Years later, our footage would help successfully prosecute a Congolese warlord in the UN International Criminal Court. But, at the time, filming in Bunia felt less like an achievement than an act of monumental stupidity. I’d been out of my depth, flying blind.

  At age twenty-nine, I left my career in television journalism to retrain as a doctor. On swapping current affairs for a caring profession, I imagined I’d put war zones behind me. Yet ironically – given that hospitals are meant to be citadels of healing – the most frightening experience of my professional life was not those hours spent under fire in Congo’s killing fields but my first night on call in a UK teaching hospital. Had anyone predicted this at the time, I’d have laughed at their hyperbole. But nothing, it turned out, quite matched for me the terror of being spat out of medical school into a world of blood, pain, distress and dying that I believed I must expertly navigate, while feeling wholly ill-equipped to do so.

  My first set of nights loomed like a prison sentence. As a newly minted doctor, I knew twenty-eight causes of pancreatitis, the names of all two hundred and six bones in the human body, the neurophysiology of stress and fear, but not – not even remotely – how to make the emergency decisions that, if I got them wrong, might end up being the death of someone. No one had taught me what to do with all my knowledge. I wasn’t even sure I could correctly pick out the sick patients from the ones I didn’t need to worry about. And yet, in dimly lit wards across the hospital at night, several hundred patients’ lives were about to rest, at least initially, in my inexpert hands. I felt like a white-coated fraud.

  In an effort to manage my imposter syndrome, I prepared for my nights like a military campaign. My Royal Air Force fighter-pilot husband – a man for whom aerial dogfights in a Tornado F3 barely even quickened the heart rate – advised me that the key, at all costs, was to ‘stay frosty’. In a forlorn effort to acquire Dave’s elusive inner frostiness, I retreated to what I knew: my textbooks, revising how to manage every life-or-death emergency I could possibly think of until – in my head at least – I was handling them all like George Clooney. I stocked up on Diet Coke, cashew nuts and moraleboosting chocolate bars. I snuck a pocket guide to eme
rgency medicine into the bottom of my rucksack and chose sensible shoes for sprinting to crash calls. And, when I arrived at my first ever hospital handover at 9 p.m., I took custody of my on-call bleep – the electronic pager through which the nurses would spend the night contacting me – with what I hoped looked like battle-weary nonchalance, while secretly wanting to vomit.

  The departing house officer handed me a barely legible list of jobs – patients needing cannulas placed in their veins, blood tests or urinary catheters – before fleeing into the night. The medical registrar, the senior doctor to whom I was meant to turn for help should I find myself out of my depth, told me in no uncertain terms that he’d be busy all night in A&E, but to bleep him if I absolutely had to. The other doctors dispersed, all looking grimly competent.

  Bleep. It started. Nurses calling me about the patients on their wards with racing hearts, plummeting blood pressure or worryingly low levels of oxygen. Bleep. They all wanted me to come immediately to assess their patients. But, even as I tried to answer the first bleep, the second and third were lighting up my pager.

  ‘For God’s sake,’ I wanted to tell them, ‘will you please bleep somebody else, because I’m not a doctor, not even remotely?’

  There was, of course, nobody else. I was alone at the start of my shift, wanting to cry, with a jobs list already covering two pages.

  Mr Frith was one of the first patients I reviewed that night. All his numbers, rattled off by a nurse on the end of a phone, were bad. Heart too fast, blood pressure too low, oxygen levels barely compatible with consciousness. Even I knew enough to rush straight to his bedside. He lay alone in the semi-darkness – eyes rolling wildly, breaths coming in short fitful gasps, lips clearly blue – trying to communicate in fractured monosyllables. A retired linguist in his early seventies, he had been admitted to hospital some ten days previously with a mild heart attack that had been complicated by a pneumonia picked up in hospital. All this was eminently reversible. There was no reason why he should not be able to return safely home to his wife of forty years. But, right now, he looked deathly. His nurse was nowhere to be seen.

  I was certain that something was terribly wrong, despite not being able to name it. The sounds in his chest, magnified by my stethoscope, were like nothing I had heard before. A grinding and rattling more mechanical than human, ugly and wrong. I guessed that Mr Frith’s heart was failing, causing fluid to swamp and overwhelm his lungs. If I was right, he was drowning before my eyes.

  Sick with dread, I fumbled to put an oxygen mask over his stubble and ran to the nurses’ station to try to find his nurse.

  ‘Who’s looking after Mr Frith, please?’ I asked the three nurses sitting behind the desk.

  ‘Who?’ said one of them. ‘Frith? Oh, you mean Bed 4. Miriam. She’s on a break.’

  ‘Well – please could you help me?’ I asked, far too hesitantly.

  ‘No. He’s not my patient.’

  ‘I – I think I need help.’

  ‘Well, you need to call your boss, then, don’t you?’

  So I did. I did not know what else to do. I bleeped the registrar once, twice, multiple times. But my calls to his bleep went unanswered. I had no nurse, no senior doctor to help me, and a patient on the brink of death. In sheer desperation, I ran down seven flights of stairs to the Emergency Department to try to physically manhandle my missing senior doctor up to my patient’s bedside. It was precisely at that moment, while I was frantically scouring A&E for help, that Mr Frith’s heart stopped beating.

  Everything I did that night was wrong, starting with my pitiful meekness. There is a code no one teaches you at medical school, a certain way of getting things done. When you find a patient in extremis, for example, you shout as loudly as you can from the bedside, ‘I need some help, please’ and four of five staff will instantly materialise. Better yet – it is not rocket science – you simply press the red emergency button beside every patient’s bed and a wardful of staff will rush to your aid. Most effectively, if you think your patient is ‘peri-arrest’ – on the brink of suffering a cardiac arrest – you put out a crash call via the hospital switchboard and in moments a crack squad of resuscitation experts should rally to the bedside.

  I violated the code. I was timid and polite when I should have been assertive. I gave the nurses none of the right cues, and I lacked the practical knowledge that a crash call is appropriate for anyone you think is about to fall off a cliff, not only those who have already done so. Perhaps it is the fear of being seen to do the wrong thing – the embarrassment of mistaking a patient’s minor unwellness for a full-blown emergency – that holds young doctors back from calling the cavalry. This reticence has the potential to cost patients their lives.

  That night, when the crash call came, I was the most junior member of the crash team, and also the farthest away from Mr Frith’s bedside. I was still in A&E, searching in vain for my registrar. The four shrill bleeps that herald an arrest call are deliberately designed to stop you in your tracks, focusing your attention on the crackling, barely audible telephonist’s voice instructing you where to assemble.

  ‘Adult arrest call. Adult arrest call. Adult crash team to Level 7. I repeat, Level 7.’

  In this case, I already knew exactly where to head. With sick clarity, I confronted the fact that I had physically abandoned my patient just before his heart has stopped beating. Horrified, wishing it were anyone but him, I ran back up the seven flights of stairs just in time to hear the consultant leading the team ask, ‘Who the hell is this “Clarke” who last saw the patient?’

  ‘It was me,’ I muttered, barely audibly, as all eyes turned on me.

  My entry in the patient’s notes, now in the hands of the consultant, was hastily scrawled and abruptly curtailed by my panicked departure. It must have looked woefully inadequate.

  ‘I’m sorry,’ I whispered, burning with shame. ‘I didn’t know what to do. I went to get help.’

  The registrar who had failed to answer my bleeps stood silently beside the consultant, eyeballing me defiantly. I did not dare mention his involvement – or, rather, the lack of it.

  Mr Frith had been submerged beneath wires, tubes and defibrillator leads. The team had already given intravenous drugs to take the pressure off the heart and lungs. The chest compressions were brutal but effective and the first electric shock brought his heart leaping back into a normal rhythm. He started to pink up and open his eyes, blooming back to life. I wanted to weep with relief and gratitude. It was slick, textbook, a rare perfect crash call – except for the fact, so it seemed to me, that, had a better doctor done a better job earlier, it might have been entirely preventable.

  As the team busied themselves transferring Mr Frith to the intensive care unit, I had never felt more incompetent. The shame and guilt made me want to quit medicine, barely before I’d begun.

  Britain’s junior doctors are often described by politicians as the ‘backbone of the NHS’, the workhorses whose slog – alongside that of the nurses, paramedics and all the other allied health professionals hard at work on the front line – keeps the NHS alive. But our first steps onto a hospital ward, heads typically crammed with facts but little life experience, can be steeped in isolation and hidden fears. In a profession that should be defined by compassion, growing a backbone can be brutal.

  Perhaps in medicine there is no way to avoid toughening up the hard way, through repeated exposure to life-or-death situations until your skills, expertise and the thickness of your skin can finally, just about, handle them. But what if this process takes place in a health service so overstretched and understaffed that its doctors, along with everyone else, feel they are routinely scrabbling against impossible odds merely to keep their patients safe, let alone dispense compassion and exemplary care? So that – even if a young doctor has acquired the experience to handle anything medicine can throw at them – they feel increasingly paralysed as a practitioner by a system that is crumbling and being rationed around them?

 
; In 2016, these questions were thrown into sharp relief by the dispute between junior doctors and the government over our terms and conditions of work. The conflict mobilised thousands of medics like me out on strike when we should have been looking after our patients. It ignited a war of words so toxic between government and doctors that their corrosive legacy will take years to repair. It drove many doctors, some of them my friends, to quit the NHS in unprecedented numbers. And ultimately, after months of conflict, it led to what were perhaps the saddest two days in NHS history: the country’s first ever all-out doctors’ strike, with complete withdrawal of junior doctor care. There were no winners during the junior doctor saga, yet no one lost as much as our patients.

  Throughout the dispute, according to government press officers, the rage, upheaval and bitterness centred on one issue alone: junior doctors’ refusal to give up their Saturday overtime. Our intractability made it impossible, they claimed, for former Prime Minister David Cameron to deliver on his general-election pledge to give the electorate a ‘truly seven-day NHS’. And the stakes could not have been higher. According to the Secretary of State for Health, Jeremy Hunt, every year in the UK eleven thousand people were losing their lives unnecessarily because too few doctors worked at the weekend.

  Hunt’s line was powerful, emotive stuff. While the doctor in me flinched at each insinuation, my journalistic self recognised a shrewd and effective political strategy. I’d learned about spin from the best. Some eighteen years earlier, as a fresh-faced TV researcher on Jonathan Dimbleby’s ITV politics show, I’d helped construct the interviews that Labour’s shrewdest spin doctors, Alastair Campbell and Peter Mandelson, had done their utmost to control. We interviewed Tony Blair a week or so before his 1997 general election victory. I remember sitting hunched on the floor over a tiny screen, jotting down soundbites to use in our ad break, when a presence loomed above me. ‘I wouldn’t bother wasting time on that,’ Campbell said, grinning mirthlessly. ‘Your boy won’t get anything from mine.’ He was absolutely right. We didn’t.