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Tuesday, July 26, 2016

Making of a Child Psychiatrist: (44) Work, if you want to call it that(3)

The reception area was a cosy hangout when there were few patients, although we got turfed out quickly enough when things got busy. There was a piece of machinery tucked into a corner of a high level desk that intrigued me (as electronic bits and pieces often have). It was a primitive facsimile machine attached to a telephone line that used a wire to apply heat to sensitized paper in a roll. I had never seen such a thing, and we were not allowed near it (of course), until we had been trained in changing the roll (often necessary late at night). It was a bit limited given you needed some sort of similar device the other end to be able to send notes or letters. It was also frustrating given the quality of the information which came was often blurred, or the paper had found a way to ruckle up. But it was intriguing, and once in a while proved its value.
I was attempting to change a roll of paper one night when there was a screech of tyres outside down the ramp, a thump followed by slamming car doors, and then the squeal of tyres as a car sped off. As we went to investigate, a man crawled towards us announcing he had ben shot in the head. He had indeed. When we lifted him onto a trolley, we could see the entry wounds; it was remarkable that he was still conscious in terms of the head injury, and the loss of blood. An emergency call went out for the Neurosurgeons, and in the meantime, blood was drawn for cross-matching, a drip line was set up, and head Xrays were organised. Within about 20 minutes he was wheeled away, and we were left looking at each other and shaking our heads at how violent South London seemed to have become.
There were interviews with police when they arrived, but none of us could identify the car. I understand our patient went straight into surgery to remove the two bullets. The report ultimately was that he had lost part of his eyesight in one eye, but remarkably little else. I guess he was able eventually to provide reasonable information to the police on the sequence of events. But as I noted earlier, you never hear much in terms of outcomes. Casualty is simply a passing show of a wide array of problems and trauma; as medical staff, we have a very temporary set of responsibilities.
My stories make it sound as if it may have been a violent place in itself. And when you hear a story like the one I have just recounted, you wonder whether staff themselves may ever be in danger. Certainly Friday and Saturday nights were often rowdy, and occasionally a staff member would be injured in a minor way by accident. There were some hefty male security staff who provided protection to the whole hospital and were available within minutes to subdue a stroppy customer. I don’t remember them being called in often, though I do have a memory of one particular night.
It was late, and Casualty customers were beginning to thin out, when some young male drunks came to the desk with a friend who had taken a solid blow to the jaw. We were busy; so they had to wait. They were rowdy, and began to be really belligerent. At first it was a polite enquiry to nursing staff as to how long they might have to wait; they were not happy with the answer, but everyone was tied up. I finished with a case and went to reception to get the notes for my next patient. As I emerged, I was confronted by one of the young men, about my height and build but a few years younger. He demanded I see his friend immediately. When I said I already had a case to see, he got really stroppy, grabbed the front of my white coat with two hands bringing my face close to his he began to abuse me and the department, spraying bits of beer-loaded spittle. When I repeated, very calmly, that I already had a case to see who was just as urgent as his friend, he almost exploded and lifted a fist to hit me. I am afraid my right knee rose rather swiftly into his groin. It was a reflex action; I did not learn it from anyone nor had I had time to plan it or even think it through. It just happened. He doubled over, letting go of my white coat. Groaning, he was led away by one of the other abusive young men. From the waiting benches, having recovered his poise a bit, he abused me, telling me he would make it his business to get me. If not tonight, then one night he would get me!
My heart was pounding, and I was both recovering from my violent act, but also very embarrassed. I had probably made the whole situation worse. As it happened, the group became much quieter, restless but with no verbal abuse. A couple of them looked daggers at me as I collected my young patient and his mother and took them to a cubicle. Once behind the curtain, the mother sympathised with the department having to cope with angry young men; I shrugged my shoulders and began to clean up a very nasty cut on a knee that required several sutures.
Several hours later, at the end of the shift I found myself quite anxious as I left Casualty and walked down Denmark Hill to our flat. I am not sure what I expected, but found myself with my right hand in the pocket of my Mackintosh, with my keys slotted uncomfortably between my fingers. I have no idea which B grade movie such an idea came from. I have no idea what I thought I might have to deal with, or what I was going to do if I had to. In fact, I reasoned I was likely to severely damage my hand from the keys as much as damaging someone else. It made no difference. For the next two weeks I found my keys creeping into my loose fist on my short walks home.
With a regular salary finding its way into the bank account from both Jan and I, we began to have ideas above our station. Perhaps we should begin to think about buying a house or a flat. No, it was much too early for that. It was still summer, and a whole year since our last holiday. Given we were both quite exhausted from our work days, and finding it difficult to get sufficient quality time together, perhaps we should have another holiday. A decision was made. We would not be having a holiday that demanded hours and hours on a Vespa scooter. We had loved our time in France and Spain, but during the past winter had found the icy cold of riding down to Thanet almost too much. In addition, Jan had never really come to terms with driving the bike even though she had made several attempts the previous year. We decided that if we were to have a holiday, perhaps we should look out for a cheap car. Jan would be much more comfortable in a car (and they usually had heaters), and she might want to complete her driving licence.
I began to look on notice boards in the hospital and medical school, bought some newspapers looking through the ‘For Sale’ lists, and talked with my friend on Coldharbour Lane who had contacts in the car trade. Eventually we found a 1962 bright red Mini for £120; it had done close to 50,000 miles, but looked in good shape. I asked a garage I had worked for to have a look at it; they said it was a good buy, the engine appeared to be running well, the tyres and brakes were good. It only had two doors, but then there were only two of us. So we decided. Despite the fact I had to sell the Vespa that had served us so well, we were excited.
My first job in Casualty did allow a one week holiday, and mine had been rostered about two-thirds the way through; I was ready for it. Jan had made some tentative enquiries in her Biochemistry Department and they were prepared to let her go. She, too, was ready for a break. So instead of just sitting around, or perhaps going to our old haunts in Thanet and staying with family, we planned a proper week off and went down to Cornwall, staying in Bed and Breakfast hotels, and getting lunches and dinners as and when we could. We dug out our old movie camera and bought a couple of reels of 8mm film intending to take silly movies like we had done with our old friends Bob and Chris.
We headed due west, staying overnight in Bath. The next morning we did the tourist thing and had a look at Cheddar Gorge. Then, being a couple of romantics, we headed for Tintagel on the West Coast; reputed to be the site of Camelot. The next day we headed further down the coast to St Ives and Penzance. The following day we came back via the New Forest, staying overnight and then heading home.
The most spectacular memory is being deep in the woods, and finding a quiet spot to make a small film on one reel of 8mm. The fantasy was of a wolf dreaming of and being seduced by red riding hood, chasing her through the woods and eventually catching her. Jan did the bits of filming of the wolf, and I filmed the bits of red riding hood – part reality and part in a fantasy world. The whole idea was to have a brief silent movie which could be played with Sam the Sham and the Pharaohs’ version of “Little Red Riding Hood” (which had been released on a 45rpm black vinyl record in 1966). We still have these romantic little treasures, and a projector that still seems to work every four or five years when we drag both out of a box.

More tomorrow….

Haiku on Pull/ Deep/ Tardy/ Question


You can pull a stunt
Which may seem to be clever
But not authentic

Pull this lever down
Simple instruction program
Male toilet training

I am perceptive
Pull the wool over my eyes
It makes me itchy


Deep under cover
Enemy territory
Now in shallow grave

She buried feelings
So deep down inside herself
Never felt again

So deep in his thoughts
He did not notice Rodin
Cover him in stone


Late for funeral
Tardy is as tardy does
Now late forever

Forest was burning
Somewhat tardy, rain arrived
Now just some embers

Thank you for calling
Know I am a bit tardy
But I am here now


Who set the question
Have you been a good girl, Jane?
Maybe A A Milne... 

Answers to questions
The complete set is online
Open book exams

A set of questions
For each and every stage
The story of life

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….