Everything was changing

Sexual intercourse began
In nineteen sixty-three
(which was rather late for me)
Between the end of the Chatterley ban
And the Beatles’ first LP

                                                 Philip Larkin.

The Beatles first LP starts with Paul McCartney calling “One, two, three, four!” Someone, I cannot remember who, observed that he was not just counting in I Saw Her Standing There, he was counting in the cultural 1960s. With a horrible symmetry, 8th December 1980 represented the end of the Beatles and the end of that open-minded, optimistic culture.  On the morning of Tuesday 9th December, I awoke abruptly and I realised that the newsreader on the radio was announcing that John Lennon had been shot dead in New York. To borrow the words of Leonard Cohen, it was like your father or your dog just died. I had admitted a patient called John Lennon the day before. The weeks that followed the famous Lennon’s death felt increasingly ominous. Medicine, politics and the world were undergoing a radical transformation, although, as is usually the case, this did not become apparent until a lot later. Everything was changing.

Front page of Mirror Newspaper with image of John Lennon

Soon after, I admitted a boyish, good-looking man who was a little younger than me. He was bright and funny, and he arrived wearing very expensive shoes. He had a severe chest infection. His chest X-Ray showed the typical picture of pneumocystis pneumonia, a condition that was seen from time to time amongst the immunocompromised. None of us had ever come across it in a fit young person before. The patient told us that he thought he had a sexually transmitted disease, and he was right. In fact, he had pretty much all of the sexually transmitted diseases that were available at the time. The most serious was hepatitis B, which, although inactive at that point, could not be treated. He was frank about how he had contracted these infections. He picked up wealthy tourists, mostly American men, at Piccadilly Circus and he would have a relationship with them for the duration of their stay in London. They took him to fine restaurants and plied him with extravagant gifts. He was his own man and he enjoyed his lifestyle. He was not concerned about the infections, which, he said, could easily be fixed with antibiotics.

In addition to his chest infection, he had an unusual skin rash. He had a mass in his thigh that we arranged to have biopsied, because we thought it might be a sarcoma. Everyone was puzzled by his condition, but he was unflappably good-humoured, cheerfully flirting with the staff, female and male alike. We treated his pneumonia and he was discharged for further investigations as an outpatient. I do not know for sure what happened to him after that, although, sadly, I can guess.

Newspaper cutting.

News about an epidemic of deaths amongst gay men in the USA started to appear in the medical journals and the newspapers about a year later, and it was eventually described as Acquired Immuno-Deficiency Syndrome. There were early theories that it was due to recreational amyl nitrate use or that it was an immune response to semen entering the blood stream through the rectal mucosa. In 1984, HIV was found to be the cause. My patient had AIDS many months before the first UK case was reported. It seems likely that people with HIV infection had been treated in UK hospitals for years, but the numbers would have been too small for the pattern of inter-related disease processes to be recognised. The unfortunate lad’s admission to the Mayday was the unnoticed beginning of a pandemic that profoundly changed sexual behaviour and medicine, and took the lives of several of my friends.

The Mayday Hospital chaplain was called Barry. He had a beard and rode a large motorbike. He worked well with distressed patients and the bereaved, irrespective of their faith or lack of it. We were friendly and I had a lot of respect for him. Our team was scheduled to be on call on Christmas Eve. A few days before Christmas, Barry asked me if I would read the Lesson at the Midnight Mass in the hospital chapel. He knew that I was an atheist and said that that did not matter. I had to tell him that it did matter to me, and that I could not take part in the service. Nicki and Barry nagged me to attend in a passive role, and eventually I agreed to go, mainly to please them. I had never been to a Midnight Mass before, and I thought it might be interesting.

When Christmas Eve came, we were busy from late afternoon. Christmas Day fell on a Thursday in 1980, which meant that primary care and other services were closed from Wednesday 24th until Monday 29th. A lot of patients were sent to A&E by GPs for assessment in anticipation of the long holiday break. Few of them would normally have merited hospital assessment, and Nicki, Ken (the new SHO) and I kept up a brisk pace of examination, advice and discharge. Mid-evening, I started to assess a 16 year old girl who had abdominal discomfort, diarrhoea and vomiting. She was not seriously unwell, but she was uncomfortable. She had just returned home after a few days away, and it sounded like she had picked up a winter diarrhoea virus, probably due to norovirus. I had been talking to her for a few minutes when Nicki asked me to come and help with a patient who was both physically and psychiatrically unwell. Ken took over the assessment of the young woman.

By 11.30, there was a lull in cases arriving at A&E, and the three of us went to the chapel for Midnight Mass. I regretted attending quite quickly. I had no problem with Barry’s service. Carols evoke a warmth of familiarity in even my cold atheist heart. What repelled me was the show of piety by one of the more unpleasant consultants. It triggered an overwhelming sense that I should not be attending a religious service. It felt as if I had betrayed something important, although I cannot say what that something was. It made me very uncomfortable and I was relieved to be called away before the end in order to go and see new arrivals at the hospital.

By 3 am, we had no more patients waiting, and we sat in the doctor’s mess with mugs of tea and mince pies, chatting. Our bleeps suddenly summoned us to a cardiac arrest in A&E. The 16 year old, who been sent home after seeing Ken, had been brought back by an emergency ambulance with blue lights and sirens. Her abdomen was bloated and her heart had stopped. After 45 minutes of furious effort to resuscitate her, we had to give up and accept that she was dead. None of us could understand why an apparently healthy 16 year old with a stomache upset had died within a few of hours of being seen, especially as she had shown no abnormalities on examination. We talked to her distressed family, which was awful, because we could offer no explanation. We pored over the notes, and had a long discussion between ourselves, but we could find no clues as to what had gone wrong.

It was by far the most disturbing death of a patient that I had experienced. When I got home I went through the motions of Christmas joylessly. I could not shake an irrational feeling that that I had done something wrong: that I should have continued assessing her myself or that I should not have gone to the Midnight Mass, although I knew that neither would have made any difference. I think of that girl as I leave hospital for the Christmas break each year. I think of her family grieving the anniversary. I think of how old she would be, had she lived. Not knowing arises regularly in clinical practice and you have to rely on doing things properly rather than knowing. Consequently, many doctors, including me, feel intensely uncomfortable if they do not work in a way that they consider correct. It makes pressure to speed up clinical work much more stressful, and it accounts for doctors’ intense dislike of overly target-driven health services.

chest X-ray with pleural effusion

Doreen was admitted to hospital with a massive pleural effusion. Her chest X-ray looked exactly the same as the one I had been shown during my surgical viva, six months earlier. She had had surgery for breast cancer some years before. The likeliest cause of an accumulation of fluid in her chest was a spread of cancer to her lung. At the time of the breast surgery, she had been told that if there was no recurrence within five years, she was cured, and she had just celebrated passing that date. She had, however, been suffering from increasing shortness of breath for months. When I cleared Doreen’s effusion, it was as we had feared. Multiple cancer metastases were visible on her chest X-ray.

Oncology had only recently developed as a distinct specialty, and we were advised about a chemotherapy regime. The treatment Doreen received was protracted and gruelling. It was mostly administered by me. She was a single woman in late middle age, and she developed a degree of trust in me that I found a little frightening, because it seemed misplaced. She insisted that I was in charge and Nicki humoured her, as it was not the right moment in Doreen’s life to have sexist assumptions challenged. The treatment was palliative, aimed at preventing the pleural effusion from returning. During chemotherapy, her white blood cell count plummeted and she became seriously immunocompromised, with a risk of being overwhelmed by a chance infection. We moved her into a side room and she was barrier nursed, which meant that gowns and masks had to be worn whenever we saw her. Her throat became painfully ulcerated. After some distressing days, her white count rose again. January progressed and we came no closer to discharging her. The date of my move to a surgical house job approached and Nicki told me that I had to warn Doreen about my imminent departure.

I knew she would be upset, and I put off telling her. It was about three days before I left that I broke the news. She was distraught. “No!” she said “you can’t leave. You’ve saved my life. If you leave, I’ll die!” I went through the explanation that I had delivered several times before: that I was the most junior member of the medical team, that I made no decisions and that I had merely followed a treatment plan made by others. She did not seem to follow what I was telling her. In retrospect, that was because I had completely missed the point. She had tears on her cheeks as I left her room. On my last day, we had a warm parting. She gave me a bottle of brandy. She hugged me, wished me well and told me she had great faith in me. Just over a week later, Nicki called me at home to let me know that Doreen had sharply deteriorated and died, just as she had said she would. It is a self-indulgence to believe that the only thing that matters in medical treatment is the technical aspects of the intervention. How treatment is done is as important as what is done. Patients can come to feel very dependent on individual doctors, and you cannot ignore that. Suddenly letting a patient down has consequences. It was a moment that forced me to acknowledge that medicine is all about relationships.

Everything was changing. The first Thatcher administration was ruthlessly shrinking the economy in the first phase of her grim and unrelenting war against the British working class and its organisations. The unemployment rate was rocketing and by the end of 1981 it had hit 10%, or 3 million people. The post-War consensus on cradle-to-grave welfare and the protection of the vulnerable was dying.

In our flat in Bromley, the sound track to 1980 had been the Clash’s London Calling!, in my opinion the last great LP of rock’s vinyl era. Although the Clash had broken through under the banner of punk, they owed a lot to older bands like Mott the Hoople and the Rolling Stones. My enduring attachment to their music proves the point for my detractor who forty years later accused me of being, amongst other things, not a genuine punk. She was right. I enjoyed the buzz of punk, but I had no real attachment to its subculture. London Calling! stands alongside a handful of other examples of perfection in the LP format, including Revolver, Pet Sounds, Highway 61 Revisited, Exile On Main Street and Horses. In its greatness, London Calling! signalled the end. The charts of 1981 were dominated by the new cold synthesiser  bands that were inspired by David Bowie’s Berlin albums. The apostolic continuity of guitar bands was broken, and the sense of a great musical community, which stretched back to the Shadows in 1960, was lost. What followed was a variety of fusions, revivals and genre cults; a market place, not a movement. In Jamaica and Brixton, roots reggae started to fade.

Being valued had made chronic overwork and poor pay more bearable, but in January 1981 we  were given the first intimations that the implicit deal between the NHS and its junior doctors would no longer be honoured. The hospital stopped providing cotton sheets in our rooms and replaced them with paper ones. We were told that these were just as comfortable and durable as cotton, but they were not. They were awful. They shredded as you slept. You woke with skin against rough blankets, surrounded by what appeared to be a lot of toilet paper. The change of attitude towards junior doctors was an early sign of the introduction of penny-pinching ‘business’ values into the NHS, the main consequences of which have been inefficiency, rising costs and alienation of the work force.

image of coin

I had my own bedroom in the Mayday doctor’s residence for the six months that I worked there. On my last day, I gathered up my possessions. Checking the draws in the desk, I found what I initially took to be a fifty pence piece. However, on closer inspection, it had the head of Marcus Garvey where the Queen’s head was normally found. It was a Jamaican fifty cents coin, and I kept it as a token of my months of toil in Croydon. I carried it in my wallet for many years, a reminder of all that had happened. I took it out a few years ago to make space for an internet banking fob. Like so many other things that I once valued, I have since mislaid it.