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Monday, July 25, 2016

Making of a Child Psychiatrist: (44) Work, if you want to call it that (2)

WARNING: If you are in any way 'squeamish', please do not read this part chapter of my story.

You become a Jack-of-all-trades working in a Casualty Department, and there is no part of the body that remains strange. During daylight hours there was always support from other departments and services, but after about 6pm you were expected to manage – even if your work is checked out in the cold light of the next morning. So we learned to take bloods and all sorts of other specimens for pathology. We were taught how to use the ECG machine, interpret the results sensibly and use that understanding to assist with accurate treatment. If a chest pain patient was in serious distress and their ECG looked like they had a disordered rhythm or signs of a coronary thrombosis, then it was reasonable to call in a medical registrar. But if you called as a matter of course just to pass on the responsibility, and ultimately the problem was adjudged to be minor, you gained a bit of a reputation. Conversely if you did not take things seriously enough, you could also land in hot water. And sometimes your registrar was busy elsewhere, or had only been asleep at night for the last 20 minutes, so you had to become more and more confident with your own decision–making. In so many ways it was a brilliant basis for my later brief career in general practice.
There were sad events. In the middle of an extremely busy evening a young woman came in complaining of abdominal pain and vaginal bleeding. She had been about 4 months pregnant, but it was clear from what we could see that she had lost her baby. There were difficulties staunching her bleeding, but initially there was not much concern, and she stayed with her husband in a curtained off cubicle, while the on-call gynaecology staff were called. Everyone was busy elsewhere. When the husband eventually raised the alarm because his wife seemed to be losing consciousness, and blood was seeping through her bedcovers, our patient was in extremis. The gynaecology registrar had still not arrived. There was controlled panic trying to get a saline drip into a vein, and suddenly everything was action as she was wheeled off to theatre for surgery under an anaesthetic. The casualty staff were subdued, but then had to get on with all the other problems of that night needing attention. We learned later that the young woman had died - an unnecessary and devastating loss of young life. There was discussion later of what might have saved her life; the general consensus was that a drip could have been placed in her arm earlier. But it was with hindsight in a rare situation; not many people who lose a baby in the early stages lose that much blood that quickly. But you never forget such events; they caution your future.
There were really odd events. One morning, a middle-aged somewhat obese man came in complaining of buttock pain, and a weeping spot that would not heal. He was triaged by a junior nurse, and then a sister asked for my help. She seemed amused, but I barely noticed as we went into the cubicle.
“So what is the story?” I asked.
“I don’t know, Doc. But I have always had a bit of an infection from time to time, ever since the war. I got some shrapnel in me, and I think there must be some bits left in me be’ind”.
The man had a large infected spot on his buttock that had begun to drain. We decided it warranted some help. “You will need a bucket,” suggested the sister. “Really?” I asked. Again she smiled, and added: “And we will need some masks”. I put on a plastic mac and gowned up with some rubber gloves, put on a mask and we incised the area of the spot. Pus oozed out in large quantity, and soon we needed to empty a kidney dish into our bucket. We went on, filling our kidney dish again. The sister suggested I might need to use my finger to break down loculi under the skin, and demonstrated. I did so and, to my surprise we found more pus, and then another loculus and more pus. Eventually we had a fair sized hole from which I needed to extricate most of my hand, and we also had a third of a bucket of extremely smelly stuff. “How did you know?” I asked, realising I had just passed some sort of initiation. “Experience”, she said as she bustled about cleaning trolleys and the cubicle, still smiling. I was glad to get rid of my gown and mac and gloves, and I seem to remember I spent rather a long time washing. We took some blood, specifically to test for Diabetes, and made a referral to General Surgical Clinic.
Another odd event was provided for me by a couple of ambulance officers one morning. If they brought a dead body to Casualty, they needed to get a certificate from one of the doctors to say the patient was DOA (dead on arrival), before they could take the body to the mortuary for further action. Apparently, I was the only doctor available, so with some trepidation, I climbed into the back of the ambulance in the courtyard. When I lifted the blanket, there was an obviously dead man laying face up on a stretcher. I estimated he was in his thirties, a strange age to die with no apparent cause. I asked the ambulance men how they had found him.
“We were called to the ground floor flat, and the front door was open. We found him in the lounge lying on his back.”
“Were there signs of a struggle, or anything?”
“Not that we could see. He was obviously dead. We just lifted him onto the stretcher, and brought him down here.”
I began to examine the fully clothed body for signs of injury, beginning with his head. As I got down to his chest, I noticed that there was blood on the stretcher, and some had dripped onto the floor of the ambulance.
“Where is the blood coming from?” I asked.
“Oh, didn’t notice that…”
“Can you help me turn him over?” I asked. We lifted our subject and I peered underneath. There for all to see was a flick knife, sticking out at an angle from the poor chap’s back.
“Oh, didn’t notice that…” my friends chorused.
“Well, he is clearly dead. And I think we may have found the cause…”
I signed my first DOA form, adding my newly minted letters MBBS underneath, and the ambulance men drove down to the mortuary. I phoned our local police to report on the incident. I didn’t hear any more, so I guess it was all dealt with.
And then there were the thirteen elderly ladies. As we got to the last months of time, the weather turned on a cold snap, with some sleet, and very icy pavements. Over two days Casualty collected thirteen cases of elderly ladies, each of whom had slipped on some ice just outside their homes, or at the local shops, and had put out their arms to stop themselves getting damaged. Xrays showed that each one of them had a classic Colles fracture to the radius bone at the wrist. The team organised the next day to have two anaesthetists, and using two surgical beds side by side, each of our dear ladies was put to sleep, and their fracture reduced by a combination of technique and brute force that left your thumbs aching. The registrar thought it an excellent opportunity for us to learn, and so two of us were shown Xrays, shown what needed to occur, had the demonstration on a couple of cases, and then were expected to reduce the fractures on our own. When the technique works, there is a satisfying click putting the end of the radius back where it should be. When it does not work first or second time, you are grateful there is an experienced registrar to take over. So I managed three successful manoeuvres, eventually, but failed on two. I never did really fancy doing Orthopaedics.
Finally there are cases that get you into trouble, sort of. Again, towards the end of my time in Casualty, I was allocated to see a young woman who claimed to have been raped within the last two hours. I took the history with a nurse as a chaperone taking her own notes, and assisting me. When it came to the physical examination, I noted all the signs of bruising pointed out by our patient, and we then (with permission) did a very gentle vulval examination, and took swabs in an attempt to gain samples of semen, but also to look for infection. I had no reason to do a vaginal examination, which in any case would have further traumatised our already distressed patient. This was in the days before much medical photography, and before the technology of iPhones so accepted by today’s society. So I drew detailed drawings of the bodily bruising, and also drew the abrasions to the vulva. I got the nurse to countersign my drawings in the notes. I was not sure what was likely to happen after that, but heard nothing for many months. Then I had a summons to appear on behalf of the prosecution in a rape case to be held at The Old Bailey in the centre of London. There was little preparation other than a short phone call from a lawyer for the prosecution who explained the process of examination and cross-examination. On the appointed day I turned up, looking as dapper as I could manage, and feeling truly overwhelmed to be ‘Appearing at the Old Bailey’. I sat outside the court until I was called. After the usual palaver with swearing in, the prosecution lawyer took me through my credentials and the history I had taken, what I had noted about the emotional state of my patient, and asked me to explain what I had drawn so well in the notes. Then I was handed over to a defence lawyer who went over the same ground, attempting to gain some change in my views perhaps. Finally he said: “In your testimony and in your notes, you used the term ‘excessive force’. Would you care to describe, in your experience, what you mean by ‘excessive force’? I remember saying something to the effect of: “Well, in my experience, consensual intercourse does not traumatise the vulva or vagina and leave the kind of marks that I saw. I believe considerable violence led to the damage I saw.” That seemed to be it. “Thank you Dr. Martin. You are excused and may stand down.” I never have enjoyed going to court, even if it is my expected duty to support patients.

Sunday, July 24, 2016

Making of a Child Psychiatrist: (44) Work, if you want to call it that (1)

WARNING: If you are in any way 'squeamish, please do not read this part chapter of my story.

The centre of the Department was the reception area. Walking wounded would appear at the front window, having entered up a ramp from the outside world, and queue up to get registered. They would then be allocated to cubicles, a nurse would take immediate details, a sister would allocate cases to either nursing care or to one of the junior doctors; we would take a history, do a preliminary examination, discuss with a registrar, write up brief notes and then do whatever was appropriate. In the early weeks, it was made clear there was a chain of command. We were not allowed to act without clear discussion of a plan. Once completed, cases were not allowed to be discharged without review by someone a bit senior, and without appropriate follow-up (Casualty, a Clinic in the hospital, or a GP) having been arranged. The learning curve was steep both for the medical practice aspects, and the bureaucratic process. There was no place for error. Discussions went on endlessly, even when we were in the refreshment room.
The alternative access was via the ambulance entrance, with most customers being wheeled direct into an available cubicle. Again there was a rapid triage discussion about the possible problem and whether junior ex-medical students would be capable of the challenge. We were there to learn our trade, but equally we were there to do work, and be part of a team. It was a challenge, but on the other and it was an enthralling immersion in clinical care.
There were easy cases like a minor sore throat; brief history of past illness and other system problems, followed by examination of throat and glands, very brief discussion of general care, and a relevant prescription from the pharmacy down the corridor. Notes written up with cryptic acronyms, we moved on to the next assigned case. But then there were more dramatic issues, like the West Indian man who arrived on a stretcher and was behind the curtains with two members of his family. Every few moments there would be a wail of: “Oh lordy, lordy, de pain…” Examination had suggested a torsion of the testis (which I could imagine was indeed extremely painful). We were waiting for the surgical registrar to review urgently for possible surgery, so we provided some hefty pain relief, which took its time to work. Junior nursing staff would smile as they passed the curtained off cubicle, or disappear into reception before bursting into giggles. I guess it was as much the deeply masculine West Indian accent added to the high-pitched wails of pain that got to people. Casualty was the place I learned to manage my personal feeling response. Not in the sense of being uncaring or callous. But coping with a wide range of people at the worst moment of their lives, you have to develop some sort of protective layer; you have a job to do.
So I learned to deal with minor cuts and grazes; how to clean the surface effectively, what to apply to promote healing and avoid infection, how to bandage different bits of anatomy. I learned how best to provide analgesia before suturing wounds of varying depth, what suture material to use if there were different layers to close, and the time it took to heal different levels of the body. For the first few weeks, everything was checked; after that you could ask for a second opinion or to have your work double-checked. But everyone was busy. I guess the grapevine was suggesting that I appeared sensible and increasingly competent. So I found myself doing increasingly complex things.
About 8pm one night half way through my time, there was a ruckus going on the ambulance bay. A detective sergeant had been in Soho with a colleague, and had found himself in a fight. Someone had drawn a stiletto, and swung at his face removing almost one side of his nose. As he turned away to protect himself, the reverse stroke had sliced into his buttock. There was a gaping wound over 15 inches long. We could nothing about his nose, though his colleague had picked up the flap and had it in a cleanish handkerchief; we needed the plastic surgeons to deal with that, but in the meantime it was placed on ice. The registrar asked me to assist in sewing up he buttock, which we cleaned up. We could then see that the wound had clean edges so, having injected our patient with analgesic, we began to sew muscles to together with strong gut sutures. Having completed that, we began on the skin, the registrar from one end and me from the other. Our patient regaled us with stories of the police beat, as we completed 75 skin sutures, and handed him over for admission and some more fine needlework. The problem with Casualty, is that you never see the longer-term result; so I never knew whether our policeman had problems, or whether we had done well.
In a similar vein, and a case that was to have ramifications for me later, about 9pm one night a unkempt man in his thirties casually walk up to reception and showed the nurse his arms. “I have been cutting myself.” He was bleeding freely. A nurse and I were allocated to do the suturing of a myriad of cuts on each arm, some shallow, some deeper. We were gowned and masked and finishing our set up when a registrar poked his head through the curtains:
“Sew him up without anaesthetic!” he said, and disappeared.
I followed and challenged him: “I am sorry, but I am not sure I can do that.”
To which he retorted: “You will do what I tell you!” and began to march off.
“Seriously, that will cause unwarranted pain, and I could not do that to a patient.”
“If you do not do what I tell you, I will report you for subordination… “Seriously?” “Seriously…” Then as an afterthought: “Listen, this guy likes pain. He will probably enjoy the experience. In any case, you will cause pain sticking needles in to get anaesthetic to each of those cuts. Now get on with it.”
When I got back into the cubicle I explained to the nurse, and she looked as troubled as I felt. But with reluctance we went ahead. We had both arms stuck out on rests; a cruciate position. Each of us cleaned the wounds on our respective sides, and then cut by cut we sewed. With each suture inserted, our patient would say: “Oh, oh, do that again!” Or, “Do it again Doc, do it again!” or some such. And he did have a sort of smile on his face. The nurse and I looked at each other amused and dismayed.
As we went on we found out that our patient was from the Maudsley, a psychiatric hospital with a lengthy and illustrious history, which happened to be just across Denmark Hill. He did not appear psychotic to my untrained eye, just troubled by his life. At some stage he had attempted suicide several times, and he had discovered that cutting himself controlled his feelings and stopped him from completing suicide.  When we had completed all the sutures, we cleaned his arms, applied bandages, and he signed himself out to return to his hospital ward across the road; “Thanks nursie, thanks doc, I will be fine.”
Who at his hospital had noticed his cutting behaviour? Why had he come across the road unaccompanied? Why did we not arrange for someone to go with him to ensure he got back to his ward? Why had the registrar reacted in such a strong way? Why did we concur, and cause further pain to a fellow human being? Who followed him up? Who followed his case from the psychiatric point of view?
I guess this case must have had a profound impact on me, and I never forgot what I felt I had been forced to do. When I was working with a young woman some forty years later, she told me that she had had similar treatment; she had been abused by the medical profession. Based on several stories from young people, my team had been researching had been research ‘Self-injury’ and its causes. This new story re-evoked my guilt and outrage, and led to a visit to our local Minister of Health to alert him to the potential problem. In a grand bureaucratic manner, he asked us to “put it in writing with times and dates and names so that his team could investigate”. It also led to state-wide training programs and television stories, and widespread distribution of manuals targeting a young people, their parents and a range of professionals. Any of you with analytic training or experience will recognise these activities as a way of 'undoing' my guilt from so long ago.
But I still feel guilty about my case from 1967. I guess the best I can do is to hold onto the memory as ‘a driver’. Maybe we have, and can continue to make a difference.

More tomorrow….

Friday, July 22, 2016

Making of a Child Psychiatrist: (43) Exams… (1)

The next few months are a blur. I really did want this. It appeared that on a good series of days, with the right questions to suit what I had been learning, and interesting clinical cases (that I may have seen before), and nice examiners, I could actually become a doctor; something I had been dreaming about since the age of 12, and had thought to be possible since about the age of 16.
The season was rolling towards winter, and Christmas. So we went out less and less, and avoided too much in the way of social contact. This suited Jan, who was often tired from working full time. I really did set about revision in a big way. I say that, but there were topics I avoided because I found them boring. For instance, I continued my difficulty with pharmacology.
At Med School there were ongoing clinical firms with increasingly high expectations. I spent less and less time in the Common Room (perhaps for reasons I have already described). I spent less and less time playing squash. I had been very keen at one time, Secretary for the club and involved in organising teams for tournaments. This just faded out. I withdrew a lot from my peer group and, if you are not living with a group, you hear less and less of what is going on. If you are married you get invited to fewer parties. From card-playing, squash-playing, party-going, thespian having fun, I became a bit boring. I had little interest in reading the News about the vagaries of the outside world. My world contracted to a tunnel. Possible daylight in about March seemed a long way away.
There were actually three different exam systems. One was the Licentiate in Medicine and Surgery of the Society of Apothecaries (LMSSA), which has not been offered since 1999, and was often seen as either a fallback for any medical student who thought they were unlikely to pass the University degree course. As an organisation, LMSSA had an illustrious history deriving from various trades going way back to about the 12th Century. Originating from the coming together of people who knew about substances that could be taken to remedy an increasing range of human ills, the Apothecaries gained a Royal Charter from James the 1st in 1617. Latterly, they were seen as the precursors of general practitioners, and the Society of Apothecaries were licensed to examine in medicine under an act of parliament from 1815.
There were some quaint rumours suggesting why it might be worth taking the examination. One was that it gave you the right to drive a flock of sheep over London Bridge; a second being the right to ask a policeman to hide you behind his cloak if you wanted to pass water. Given I could never see myself in either of those situations, I could not see the point. One contrary rumour was that you could be examined in Latin, and I deemed my 4th form Latin was now defunct. Two other reasons lurking in my mind were that I had been told there was a strong focus on medication and an understanding of pharmacology, the other that I doubted I would be ready for examination by the date required. I persuaded myself I would not need it; in other words I ‘piked’!
The Conjoint LRCP, MRCS examination was run jointly by the College of Physicians (which gained its Royal charter in 1518) and the College of Surgeons. It was scheduled to begin in early March. This was much more recognised, and would have allowed me to begin to practice medicine and complete further training anywhere. Again, it was thought of as insurance against failing the University degree; at that it was cheap at the price. My preclinical and clinical training fulfilled all the requirements for examination, so I put in my application to the Conjoint Examining Board with the appropriate fee.
As expected, the structure of exams included written papers, clinical examination and vivae voce. Perhaps it is not surprising to have forgotten the contents of papers and viva details given the passage of 50 years. Sadly, I did not save the printed papers. All I really remember is some weeks later attending an overwhelming edifice with marble flooring and imposing columns, where we milled about anxiously awaiting the sentence. One by one we were called to an imposing lectern; those who had passed were asked to enter the portals behind the lectern, and turn left. Those who had failed were left to wander back out onto the street.
Once inside we were given a short address of welcome and congratulation, and then asked to confirm our personal details and sign a register. We were told that we could now use the post-nominal letters LRCP, MRCS, and that our certificates would be posted out within the next few weeks. That was it; I was an honorary doctor. But not yet a ‘proper’ doctor with a University degree! Those exams were a couple of weeks away. So, despite some sense of relief, celebrations were muted.
These processes of examination are never to be taken as just a matter of course. You may have the basic ability, have attended all the teaching offered, have worked hard in small group training sessions, and studied assiduously. But there are always pitfalls - questions in exam papers that seem impossible to answer, or impossible to answer within the allotted time; tired out patients in the clinicals, who have answered the same questions twenty times and have had enough; examiners in the Orals who are getting more grumpy and caustic as the day wears on.
There are few things I remember about finals. From memory, the writtens took place morning and afternoon over several days at Queen’s Square in London. I remember struggling to manage some questions, but other than that all I remember are the toilets. They were the old penny in a slot type, for which you had to be prepared. They were clean, but absolutely covered in graffiti - some rather funny, others absolutely unrepeatable in good company. The one I remember was: “Here am I broken hearted, paid a penny and only farted”. Ah, so true. I believe subsequent clinical exams were at a number of hospitals around London, but I cannot recall where, nor the content of exams.
So a couple of weeks later it was all over. On the appointed day, results were posted behind glass in a freestanding noticeboard outside Senate House of the University of London in Malet Street. I did not want to go with others, so I turned up alone in the late afternoon. The square was empty apart from two students with University College Hospital scarves, sauntering back from the Board looking very pale but smiling. Rather gauche, I asked: “Did you pass?” to a conjoint “Yes, thank God” and they walked on. One turned and, as an afterthought, wished me luck. Heart pounding, and slightly blurry eyed, I had trouble finding my name, but there it was sandwiched between a Machin and another Martin with different initials. My visual blurring became worse as the tears ran free, and I crunched back over the gravel. I sat for a very long time on the Vespa, before feeling safe enough to drive back to Camberwell Grove to tell Jan. We breathed a collective sigh of relief, given it meant I would now be able to carry some of the financial burden of our lives. More than that, I realised how traumatised we had both been by the months of intensive study, and the repeated trauma of exams under pressure. Of course our marriage was only nearing its first anniversary, but if we could survive all we had been through in the lead up to the exam program, we could probably survive anything. I am not sure that I realised, nor fully acknowledged just how much I had been supported by my stoic little wife. We went down to a public phone box to let both sides of the family know about the results, and discuss plans for a weekend of celebration.
So, should I be concerned that I have so little memory of the examination process? I do not believe so. When the level of stress is so high, consistently every day, and when you are having to perform at the peak of your ability, think on your feet, and use every bit of your memory for the task in hand, the brain adopts a protective mechanism of shutting off anything that is not focused on the issues in hand; anything that is not germane. I have argued that I have brilliant recall of clinical casework, with images of people, the circumstances at the time, and the information provided. But the exams were different; sadly I have to say that the patients who offered their services to be examined repeatedly for the purposes of the exams were somehow ‘other’; they were not my patients to be cared about and cured. Like the environments, the papers, and the examiners who interviewed me, they were sadly just part of a process that I had to endure. As we shall see in a later narrative, I think if I had had a particularly bad experience that had led directly to failure, then my memory would have remembered the episode, and replayed it repeatedly – possibly to see how (or perhaps whether) the episode could have had a different outcome. Luckily that was not the case, and I can let it all rest.   
The next day, I found out in dribs and drabs that all of my peers at King’s had passed. Of course I had been keen to know about my old flatmates. Within days, the allocation of house jobs was posted on the Information board. The next year was now secure with my first job to be in Casualty for 6 months, followed by my treasured job in the Professorial Medical Unit. As a married couple, we had also scored one of the medical officer flats on Denmark Hill, just down the road from King’s. So there was a mad scramble to pack up our beloved flat, and get family support to move, as soon as the hospital flat was emptied and cleaned. We were able to walk to and from work each day, and the Vespa, parked in the car park in front of the flats, began to look forlorn.
On Monday 15th May 1967, at an annual salary of £800 per annum as a very junior house officer with newly minted qualifications, I began work in the Accident and Emergency Department at King’s. Yes, this is the place now made famous by the British television program ‘24 hours in Emergency’. In many ways, watching the TV series, it appears that not much has changed over the years in terms of the space available, and the sense of excitement or impending doom (however you like to construe it) is well transmitted. That probably sounds like a glib, superficial comment given advances in technology, and training. But accidents and acute medical problems are similar through time and space. How effectively we deal with them does in part depend on technology, but mostly depends on the skills and teamwork trained into the system.
Alongside about 50 nursing staff on rotation, there were 10 medical officers working shifts, and this included four registrars at differing levels of seniority. With a day off each week, my monthly roster was 96 hours a week, followed by a couple of weeks of 78 hours, followed by an easy week of 66 hours, so we were working very long hours each day. Each week included nights shared amongst us, when we were expected to sleep in a single room on the premises (wives not allowed). As you would know from watching the TV series, there is no real regularity about casualty work, so there are some quiet times, and some quiet days. While I was there, we saw and managed an average of 1400 people a day, but of course many cases were dealt with by nursing staff, although the rule was that all new cases had to have a medical oversight. The whole process, of course, was backed up by the rest of the hospital; so many cases coming through were very quickly sent to specialist units for urgent care.
What fascinates me looking back after all these years is that, contrary to the recently completed examination process (which is a blank), I can remember the atmosphere. I remember so many cases in some detail (even if I have forgotten the names), and I was to be forever grateful for the training I gained. After a brief induction, we were straight into it, with decisions made up the chain about what we may be competent to deal with. And you were aware that in the confined space, there was a tight monitoring process going on. Once again, I became aware of the high level of training of nurses, even at an early level of experience. And that sense of close hierarchical management was ever present.

More tomorrow….