Bounded in a nutshell

It was a General Medical Council requirement that I should do surgical on-call whether I liked it or not. My main duties were at St George’s Hospital, Tooting, looking after patients admitted for elective surgery. No emergency work meant no on-call, so a bizarre arrangement was contrived in order to satisfy the GMC. One night in five, I slept in the hospital, covering the same handful of patients that I looked after during the day. There was rarely anything to do.  I was so bored over one pointless on-call weekend that, after seeing all of my patients on Saturday morning, I went back to bed and stayed there.

Gus Singh was also on-call, and he dropped into my room for a cup of coffee on the Sunday afternoon. Gus was from Peterborough. He was clever, well-read and deployed an acerbic wit. When we were medical students, he once commented on the ridiculous, inward-looking world of medicine, quoting Hamlet:

I could be bounded in a nutshell, and count myself a king of infinite space – were it not that I have bad dreams.

Gus had been running between patients all weekend, and he was affronted to find me still in bed, reading a book. What drew his wrath was not the inequity of our workloads, but the fact that I was reading Conan Doyle’s Sherlock Holmes stories. He said that I was debasing myself by reading an author so lacking in literary merit. My retort was that I was quite miserable enough from being stuck in the hospital with nothing to do, without reading something that was heavy going. I said that this was probably why so few prisoners read Charles Bukowski.

Photograph of St James Hospital

In order to gain mandatory experience of surgical emergencies, once in a while I spent the night at St James’ Hospital, Balham, covering  A&E and the surgical wards. The infrequency of these duties meant that I never got to know the staff, and I was effectively working alongside strangers. It was not onerous, but working alone at night felt just as bleak as doing nothing at all in Tooting. Late one evening, I assessed a woman who had been brought to hospital by her daughter. The younger woman pleaded with me to admit her mother, who had a severe alcohol problem. She had been too disorganised to see a doctor about her sore mouth. When I examined her, there was a large deeply-ulcerated mass on the side of her tongue, and hard lymph nodes in her neck. It was likely that the mass was an oral cancer, which is common amongst heavy drinkers. Her daughter had kept her away from alcohol all day, so that she could bring her for medical assessment in a sober condition. She wanted her to be detoxified and assessed. She feared that if her mother went home, she would drink and forget medical appointments, just as she had missed all of the previous appointments that had been made for her.

The patient was painfully thin and she looked much older than her years. She wanted treatment, but she also wanted vodka. She was starting to show signs of withdrawal. She had a tremor that was so coarse that when I gave her a drink, all of the water slopped out of the paper cup. There was no shortage of surgical beds, and I felt that the daughter’s plan was reasonable, given her mother’s lifestyle and the ominous appearances of the tumour.

I called a surgical senior registrar that I had never met. He was, technically speaking, supervising me. He told me to send the patient home with an urgent outpatient appointment. I explained that it was highly unlikely that she would keep an appointment. He said that her lifestyle was no concern of his. If she chose not to keep an appointment, that was up to her. Admitting her, he said, would be a waste of time. I put down the phone and in defiance of his explicit instruction, I sent her to a ward, where I set up a detoxification regime. I wrote a detailed justification for my insubordination in the case notes. Trying to get services to respond appropriately to patients’ circumstances was difficult then, and it is even more difficult now. I would like to be able to report that the patient detoxified, had treatment for the cancer, and led a much happier life from then on. In reality, she discharged herself first thing in the morning. Her need for alcohol had overwhelmed her desire for treatment. The senior registrar was proven right, but I felt that I had at least given her a chance.

One night, I was called at 3 a.m. to see a patient of Mr Gillespie’s. He was an older man who had had a major operation that afternoon. A portion of his oesophagus had been removed because it was cancerous. His oesophagus and stomach had been stitched together, forming an anastomosis. Anastomoses are fragile post-operatively. The patient was not allowed to eat or drink and he had a nasogastric tube in place. This was to prevent vomiting, which would place a mechanical strain on the anastomosis and risk acid getting into his chest in the area around his heart and lungs.

diagram showing the correct position of a nasogastric tube

The nurses asked me to see him because he had woken from sleep and, disorientated, he had pulled the tube out. I was expected to make the decision whether to put it back in. Nurses routinely inserted these tubes, but there was a risk in this case that the tube would find its way through the anastomosis into his chest, causing a serious infection. In the way that things worked in those days, experienced nurses were asking a novice doctor to do a tricky manoeuvre. I was not convinced that I should try to do it at all. I was on the horns of a true dilemma, whereby all available options seemed bad. Without a tube there was the risk that he would vomit and, in the worst case, the anastomosis might break down. If I put it back in, I might push it through the anastomosis. On this particular night, the only person available for advice was Mr Gillespie himself, tucked up in bed somewhere in his six-toilet house out on the Downs. I am ashamed to say that I chose not to phone him, although I did not expect him to react badly if I did. Much later, I came to realise that asking for advice is a sign of maturity, not weakness. As a senior trainee, I frequently woke consultants, but this lay far ahead. I was still in thrall to a hospital subculture, where asking for advice was the last resort. Emboldened by nursing opinion, I inserted the nasogastric tube very carefully and arranged for an X-ray to be done first thing in the morning.

When the morning came, the films showed that the end of the nasogastric tube had gone straight through the anastomosis. It was sitting next to the unfortunate man’s heart. I stared at the films mournfully. A passing surgeon-in-training glanced at them and unhelpfully remarked that you should never do that.  I removed the tube, started him on antibiotics and went straight to James Gillespie’s office to confess. I was worried about the effect of my mistake on the patient, and I suddenly had doubts that I was cut out for a career in medicine. Mr Gillespie praised me for fronting up so promptly. “It’s alright, Rob, I’ve done it dozens of times myself!” I was quite certain that he had not. “Don’t worry, he’ll be fine”. His recovery was, indeed, uneventful.

Mr Gillespie was my principal supervisor, and thankfully I spent more time with him than with the unlikeable MK. Operating with MK was the low point of the week. Many of the procedures he carried out were revisions of previous biliary surgery. His work required intense concentration and meticulous technique. The operations were difficult and protracted. I could see why he was tense whilst operating. I found it more difficult to understand why he rarely explained anything, or showed me what he was doing. There was a lot of snapping at me for failing to intuitively know he wanted me to do. From childhood, I have pushed back hard when people try to bully me, but I was chained to him for 12 weeks, so I kept my head down. Or possibly I kept my head bowed. Either way, it did not feel good.

Most people become irritable when stressed, but MK was irritable most of the time. One day, I was doing a ward round with him and a patient’s X-ray films were not available. The nurse told him that they were in the radiology department, awaiting a radiologist’s report. He ranted that the report was a complete waste of time and that he wanted to see the films immediately. They could not be found. He angrily instructed me that I was to carry all of the X-ray films for all of his patients with me at all times, just in case he wanted to see them. Under no circumstances was I to give them back to the radiology department, no matter what the consultant radiologists might say to me. He omitted to say what I was supposed to do with the films when I was off duty. Whether I put them in my locker or took them home, they would not be available to him or anybody else. It was a characteristically childish instruction, and I ignored it. I had opted for a strategy of passive resistance in the face of his unreasonable demands, which helped me to retain a shred of self-respect through thirteen weeks of intermittent misery.

Many of MK’s patients had scarring, or strictures, of their biliary tree following routine surgery elsewhere. We saw a lady on a ward round who had been admitted for revision surgery the next day. MK went through a rapid-fire outline of what he proposed to do and then asked her to sign a consent form. His bedside manner often left a lot to be desired, and on this occasion he was impatient and rather contemptuous of her questions. The patient asked for time to think about whether she wanted to go ahead. MK replied that she had had plenty of time to think about it prior to admission. There was an impasse. MK turned to me and, in a voice that was loud enough for the whole ward to hear, told me to get her seen by a psychiatrist. Then he moved to the next bed. Later, I went back to smooth things over with the patient, who was furious. “I’m not letting him anywhere near me. He’s horrible!” she said. I did not bother to defend him, but I did discuss with her the difficulty in getting similarly skilled surgery elsewhere. She was immovable.

The next day, a psychiatric senior registrar came to the ward to assess her. It was my first encounter with Mohammed Abou-Saleh. Mohammed and I worked together as psychiatric trainees at St George’s, and he was instrumental in persuading me to apply for a consultant post in Liverpool, where he was senior lecturer. After talking with the patient, he came and told me that he could find no psychiatric disorder, but that the patient had no faith in her surgeon. He wrote this opinion in her case notes, and left. I was there when MK read what he had written. “Right!” he shouted, “that’s the end of his career in this hospital!” Mohammed has been Professor of Psychiatry at St George’s for many years.

The contrast between the two surgeons was highlighted in a week when I assisted each of them in a routine cholecystectomy, or gall bladder removal. Because MK spent much of his time repairing damage from cholecystectomies that had gone wrong, he proceeded very carefully when he did the operation himself. This included the unusual step of doing X-Rays on the operating table to make sure that all of the ducts were patent, a procedure that was known as an operative T-tube cholangiogram. On this occasion, the patient was in the operating theatre for 90 minutes. Two days later, James Gillespie removed a gall bladder at his usual lightning speed. “Six minutes from incision to wound closure, Mr Gillespie” I said. “Yes” he said, “the gall-bladder was rather stuck down”. Mr Gillespie’s patient was discharged a week before MK’s.

One day, I was discussing prima donna behaviour amongst surgeons with an anaesthetist. He told me that, a few years earlier, he had been working in an operating theatre in the USA. A world-famous surgeon became increasingly angry about a hapless junior doctor’s performance with a sucker, which was meant to keep the operative field clear of blood. Eventually the surgeon asked the nurse to pass him a liver retractor. He used the large steel instrument to sharply whack the knuckles of the assisting doctor. “Now suck up the fucking blood!” he said. After a pause, the victim asked the nurse for a liver retractor, leant over the patient and grabbed the surgeon by the neck of his surgical gown. He threatened him with the retractor, saying “If you ever hit me again, I’ll bust your fucking brains out”. Then he walked out of the operating theatre and out of the job. I liked the story, but I doubt it was accurate. I have heard similar stories involving different surgeons in different places. It is noticeable that the tale is always told by a witness, never by the protagonist. These urban myths tell of fantasies born out of humiliation. A sufficient number of junior doctors struggled with dreadful behaviour from senior surgeons that a whole revenge mythology grew up around it.

MK was a first-generation graduate who grew up in the East End. He was short and over-weight. He was a musician, who smoked and swore a lot. He had an unshakeable sense of his own rightness. I suspect that he saw himself as something of an iconoclast. In retrospect, and with dismay, I can see that we had much in common. In all probability, he struggled with some of the same class transition issues that I did. Maybe the difference between us lies in his identification with the aggressor. In other words, during his training, he chose to take on the characteristics of those senior doctors that made him anxious, because doing so made him feel safer. I would like to think that I have taken a different path. Some people who have encountered me as colleagues have not liked me, and they might disagree. I recognise that I may be a lot more like MK than I care to admit.