Not in the prescription

I have a framed picture on my dining room wall that was left to me by my grandmother when she died. It was given to her for her 17th birthday by a friend when they were both training to be nurses during the First World War. My grandmother married before she qualified and, as a consequence, she had to give up nursing. The picture is a print of a patriotic image, showing a nurse in uniform holding a glass vial of medicine whilst kissing a male patient who wears military pyjamas. The caption reads “Not In The Prescription”. It hung in my grandmother’s lounge for 65 years. It has had a range of meanings for me over the years. It illustrates the lamentable tradition of conflating female nurses’ caring role with sexual availability.

Postcard picture of a nurse kissing a patient

In recent times, female surgical trainees have started a Me Too movement, and the revelations are truly shocking. It should come as a surprise to no one that medicine has a problem with institutional sexism, but reports of high rates of sexual assault, sexual coercion and rape cannot be reconciled with any model of what a trusted profession should be. The only sign of progress since I was young is the fact that women have forced the profession to take them more seriously when they speak out, although it still comes at a high cost to those who make disclosures. The trope of the nurse as sexually available carer arose when the roles of doctor and nurse were more sharply gendered than they are now. Images of saucy antics between male doctors and female nurses, as depicted in lame comedy films and comic seaside postcards, were not harmless fun. They caricatured a toxic reality. Nurses were implicitly expected to take a subservient role, professionally, socially and sexually, and the fact that this was culturally acceptable exposes how oppressive the configuration really was. I do not suggest that all male doctors were unpleasant sexual predators nor that female nurses were passively accepting of their lot. However, sexually unscrupulous doctors within medicine abused their professional relationships without opprobrium until comparatively recently

Roland Fanthorpe and the senior nurses on our ward had a warm, professional relationship.They had worked together for some years, they shared the same values and they operated as a well-ordered team, where each member understood their role. It was noticeable that there were rarely nurses in the ward office, because everyone was around the ward, doing things with patients and their relatives.

Although I had been warned about her, I decided to make up my own mind up about Val, the sister on the other ward. At first, she was rather more stand-offish than the sisters on our ward, and she introduced herself to me in a business-like manner. The problem, she told me, with having patients on her ward that ‘belonged’ to another team was that they tended to be neglected. Medical staff would visit as an afterthought, when the work elsewhere was done, and sometimes the patient was forgotten altogether. She told me that she expected my patients on her ward to get their fair share of medical attention, and she would be bleeping me regularly if this did not happen. This seemed reasonable to me, and I did my best to meet her expectations. I got on well with her more or less straight away.

I have worked with quite a few women like Val over the years. They are assertive, confident in their professional values and a bit demanding. They are unimpressed by hierarchies and insist that respect must be earned. They get things done, but they rattle some men, who often dismiss them with harsh judgements and sexual innuendo. This is rarely done to their faces. Personally, I like working with intelligent people who are focussed on the job and take no shit. I am married to someone like that. As our relationship became warmer, Val told me that the doctor who had warned me about her had been lazy and vain, more interested in trying to impress the nurses than getting on with the job in hand. She was frank that she had shown him the respect that she felt he deserved, which was none.

 Val was a single woman on the cusp of middle age who rarely spoke about her personal life. As time went on, she became positively flirtatious, on one occasion introducing me to a new staff nurse as the Adonis of the Mayday Hospital. It was a boundaried, playful flirtation. On one occasion, I performed a pleural biopsy on a patient on her ward. She bleeped me later in the day to say that I had better come and look at the pathology report, because it mentioned hepatocytes. This suggested that I had biopsied the patient’s liver, not their pleura, the equivalent of having stabbed them. I rushed to the ward in a flap, where Val had left the report on the results clip. When I read it, the biopsy showed normal pleura. The warning about Val had been widely off the mark, and I wonder how many more harridans the doctor encountered in the years that followed. I imagine it was quite a few.

In those far off times, there was a separate doctors’ dining room, and the entire medical staff met there for lunch. The food came in a trolley from the main staff dining room and, although edible, it was standard post-War British canteen fare: overcooked, lukewarm and under-seasoned. Although separate dining facilities were a mark of privilege, like named car parking bays for consultants, there were real advantages in the arrangement. Meeting together every day facilitated discussions about patients and advice from other specialties. The most important benefit was that  it generated a sense of collective identity. Teams can only exist when they meet together regularly. Talking with each other every day avoided the modern pattern where inpatients become objects in an institutional game of pass-the-parcel, with no one prepared to take responsibility for their care.

 The consultants sat together on a separate table. Unable to hear what was being said, I enjoyed watching them. There were numerous non-verbal clues to their friendships, enmities and hierarchies. Cardiologists had a high status in medicine, but the cardiologist at the Mayday appeared to be less than fully embraced by the consultant group. I tried to work out why he was on the edge of his peer group, unable to break into it. A consultant pathologist was also marginal. He was a shy man who rarely made eye contact.  He turned out to be an active member of the Sherlock Holmes Society of London. One day, Nicki asked me why I was watching the consultants and I explained to her what I observed and what I thought was going on between them. She was amused: “You really are a psychiatrist already, aren’t you?” I have thought about the remark over the years. She was right. My primary skills as a psychiatrist are observational, and they existed long before I started specialist training.

 My domestic cluelessness did not improve during my six months of exhaustion. To help us with our irregular homelife, my mother bought us a slow cooker. The idea was that we could throw some ingredients in before going to work, and the meal would be ready to eat as soon as we got home. It was a thoughtful gift, but we came to regard the appliance as untrustworthy, and possibly demonic. The first thing we cooked in it was chilli con carne. We threw everything in, as instructed, and it was delicious, with really nice, nutty red kidney beans. We were both horrendously ill overnight. We had to take the next day off sick with severe gastrointestinal symptoms. Phytohemagglutinin is the toxin in undercooked kidney beans, and consuming a single bean is enough to make you ill. We ate quite a few, and we were lucky not to be hospitalised. Our slow cooker is still known as the slow poisoner. It is a misnomer, because the effect was almost instant.

 The practice of medicine involves a lot of compromise between what is ideal and what is possible. As a student, I heard consultants advise manual labourers in their late-50s that they should change their job, which was impossible for them. More realistic advice might actually have been followed. Judgements over compromise are common in psychiatry, where you often have to balance conflicting risks . However, it is easy to get compromise wrong, and I learnt the first of a series of hard lessons about it at the Mayday.

When people suffer from a serious blood clot, they are often given warfarin to prevent a recurrence. Warfarin slows blood clotting and, as well as its medical use, it is sold as a rat poison. Even a little too much leads to lethal bleeding. It’s a tricky drug, and you have to monitor people’s clotting time regularly. Too little and the blood clot may recur; too much and the patient may bleed uncontrollably. One of my jobs was monitor the warfarin patients after discharge. I conducted a small clinic from the ward. On one occasion, a very fit retired man with a deep suntan turned up. He chatted excitedly, as he was due to fly to Spain the next day for a six-week holiday. I took his blood and asked him to wait while I got the result. When this arrived, his clotting time was far too short and the dose of Warfarin needed to be increased. The problem with this was that the impact of even a small increase in dose is unpredictable, so every change demands another check of clotting time after a week. He begged me not to make him cancel his holiday. “I’ll be alright” he insisted, as people often do, in the belief that bad things cannot happen to them, or that willpower is sufficient to keep them well. My dilemma was that I could either make no change, in which he might get a deep vein thrombosis on the flight, followed by a pulmonary embolism, or I could make an small increase, which, if it went wrong, could lead to him exsanguinating on a Mediterranean beach.

I could claim that the patient ignored my advice not to go to Spain, but that would not be true. He wanted me to tell him that he could have his holiday as planned. I did not have the heart to make him cancel, so I made a modest increase, warned him of the need to seek medical attention if any blood appeared anywhere that it should not be, and arranged to see him again as soon as he got back. He left in a very good mood, but I immediately knew that I had done the wrong thing. A worry about him nagged at the back of my head for the whole six weeks, and I sometimes awoke feeling anxious about it. At the end of six weeks, he bounced onto the ward looking the picture of good health and said “See, I told you I’d be alright”. My relief was short lived. His clotting time was grossly too long. If he had cut himself he would have suffered major blood loss. I had to admit him and give him intravenous vitamin K to reverse the effects of the overdose of warfarin. On discharge, his parting comment was “It was worth it! Thanks for letting me have a really great holiday, Doc!”. I think “You spineless idiot, you came within a whisker of killing me” might have been more to the point.

My wife and I had lived a very frugal lifestyle until we qualified. Clinical medical students were paid their local authority grants in quarterly instalments, and when my sister went to university too, I received a full grant. We were so good at being careful with money that I forgot to pick up my spring payment in the final year, and it was still there when I went for my summer cheque. We never became over drawn at the bank, and we received no extra money from our families. So when I finally received a salary as a house officer, it felt as if we had untold wealth. It was not that junior doctors were generously paid, but the number of poorly remunerated hours worked was so huge that the actual salary was a 300% increase on our previous income. Our outgoings were minimal. My first annual Medical Defence Union subscription was £15 (it eventually rose to over one hundred times this figure, despite my lack of risk factors such as being a surgeon or doing private practice).

Now that I had some money, I could afford to impulse-buy guitars, a habit that has persisted until now. There was a guitar shop in Croydon, a one-man operation that mainly sold second hand instruments.  I dropped in on my way home one day. As I went in, Francis Rossi, the front man from Status Quo, came out, with a small child clutching his hand. I was not surprised to see him. His family owned the Rossi ice-cream vans that traded outside of our school, and I had seen him around South London before. As a teenager I had vaguely known his younger brother, Dominic. Although I did not consider Francis Rossi to be a good guitarist, he was a rock star, and I took his presence to be an endorsement of the shop. I was looking for an acoustic guitar, and there was not much in the shop that interested me until I noticed an unusually shaped guitar tucked away on a high shelf. The shop owner assured me that I did not want buy to  it, but I insisted he got it out. It was a rather bashed up German Framus jumbo acoustic with a cut way. The scratch plate had been replaced with a nasty piece of blue plastic, and the action was a bit high, but it sounded fantastic. He sold it to me for £30, and I used it daily for decades, until one night a visitor stood on it on the way to the toilet.

Another benefit of our new found wealth was a proper holiday, a week in Crete in October 1980. As far as I could tell, almost everyone in the NHS went on holiday to the Greek islands at that time. Health professionals always seem to go on holiday to the same places; the destinations change, but the pattern of sticking together persists. I have met friends, or friends of friends, on holiday abroad on numerous occasions. We had a really good time in end-of-season warmth at a small hotel in Rethymnon. At that time, Crete was unspoilt and a lot of the population remembered the German occupation with bitterness. There was a corresponding warmth towards British tourists. Of course, we were completely undeserving, having been born ten years after the end of the War. On several occasions, drinks were sent to our table by older men. One night, a meal in a small taverna turned into a multinational party and we got very drunk on retsina. Consuming excess retsina is definitely a once-in-a-lifetime experience, and I am still not ready to drink it again. In fact, I am pretty certain that the smell of retsina would make me throw up. We made a day trip to Heraklion and sat in the sunshine outside of a bar, watching life go by. When I got back to work, one of the staff nurses said “I saw you having a drink in the square in the middle of Heraklion last week”.

Not long after the holiday, Marie moved on to a different job. There was a gap before her replacement arrived, and in the interim, a locum came to work with us. He was a good deal older than Nicki and me, and he told us he was returning to medical practice after a long period of working as a freelance writer. He told us that he had had many humorous articles published in national magazines. This surprised me because he was not remotely funny in person. In fact, I regarded him as a tedious liability. When on call on Saturday nights, we often sent someone out for a curry, which we would then eat together in the doctors’ mess. When we asked the locum what he would like to eat, he asked for a brain curry, or failing that, a fish curry. In response, I just looked at him. On my return I told him the local takeaway sold neither, although I had not even asked. I left him curry-less as a punishment for being tiresome. Every time we got a call for a cardiac arrest he would tear off in a random direction, not waiting to find out where he was going. On one occasion, he ran in the wrong direction with the cardiac arrest trolley and I had to physically restrain him. After a while, Nicki and I would not let him do anything at all. It was easier for us to do his work for him. Eventually, we told Dr Fanthorpe that he was unsafe. I do not know if any action was taken. In those days, incompetent doctors floated between jobs for years.

Back in Bromley, our small friendship group sought out the anachronistic remnants of  British working class life, such as eel and pie shops, old-fashioned street markets and decaying seaside resorts. As part of this, I was interested in tattoos and tattoo artists. I have three offspring and two of them have multiple tattoos. Unlike now, tattoos were not generally popular amongst the young. Chrissy, who lived downstairs from us and who rode a huge motorbike, had a discreet butterfly tattoo on her buttock. George, my childhood friend turned dodgy businessman, had a grandmother from Bermondsey who had a tattoo on her arm, as well as a split earlobe where an earring had been pulled out. These tattoos on women were exceptional, and in both cases they were signifiers of an outsider social affiliation. Tattoos were mostly seen on seafarers, servicemen and bikers. People who get ill tend to be old, and at the Mayday I saw regularly saw patients who had been born towards the end of the 19th century. Many of the men had served in the Army in far flung parts of the British Empire. Some of them had the most amazing tattoos that they had acquired during overseas postings, especially in South Asia. I saw tattoos of regimental colours across men’s chests, and one elderly Londoner had a huge portrait of King George the Fifth on his back, where he could not see it. I noticed that his religion was recorded as Muslim. It turned out that his grandfather had migrated to London from Turkey during the Crimean war. The family had remained faithful to Islam, despite lack of local access to an imam or a local mosque.

photograph of the back of a man with multiple ornate tattoos on his back and arms Captain Elvy 1943

I suspect that my colleagues felt that I sometimes got over-involved in efforts to treat the untreatable. There was one night when I did not go to bed at all.  Bleeding from peptic ulcers was a common medical emergency and, if it was severe, it was life threatening. It required emergency surgery and this was only possible if the patient was well enough to survive the anaesthetic. On the no-sleep night, I admitted an older man who was, by his family’s account, normally very fit and active. He was vomiting copious amounts of blood and he was very ill. He was not fit enough for surgery, so we treated him with a drug, cimetidine. This is a proton pump inhibitor and it had only recently been introduced. The idea was to prevent his stomach from making acid, in the hope that this would stop aggravating the ulcer.

We gave him a blood transfusion to replace the loss from bleeding. The hope was that he would improve sufficiently to allow surgery, or that the ulcer would heal on its own. The poor man was passing melaena, which is a type of diarrhoea composed of altered blood. It has the most unpleasant aroma, which, once smelt, is never forgotten. As always, the supply of blood in London was limited, and the blood bank could only spare two units in his blood group. His haemoglobin level was very low, and he was at real risk of bleeding to death.

I was so concerned that an otherwise fit man would die unnecessarily, that I worked all night trying to keep him alive. I contacted the blood bank several times that night to get more blood, and had to fiercely argue my case every time. At one stage, the doctor at the other end of the phone suggested that I should just pour the units of blood straight into the bed, cutting out the middle man, because he did not think it was helping. The patient started to improve at around five a.m., and I went for a shower just as Nicki was leaving her room for breakfast. The ulcer healed without surgery, and he was discharged. Dr Fanthorpe told him that I had saved his life. Most of my work involved following well-established treatment regimes, and this was one of the few occasions at the Mayday when I felt that I had made a specific decision that had prevented someone from dying. The crucial choice had been to stay up until he started improving.