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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….

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