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Wednesday, September 28, 2016

Making of a Child Psychiatrist: (45) Working in Medicine (1)

At the end of my 6 months I moved into the next challenge – as one of two house physicians to the Professorial Department of Medicine. For many reasons, I am not sure I was ready. Where Casualty had been a steep curve in learning techniques to deal with even the most serious of trauma, yet filled with satisfaction because of the teamwork, Medicine was much more serious. It was an academic unit where registrars and medical staff seemed to be highly competitive, vying to know more than the next person or at least score off them. Days began with lengthy ward rounds where I felt consistently under pressure to perform. Questions would be asked; just simple things like the most recent blood pressure, and if the student who had clerked the patient did not know, everyone would turn to me. I was next one up the chain. I had been on the ward all the previous day and half the night, I had spent considerable time with the patient and had written the last comments in the notes; I should know. The senior registrar, or the consultant leading that round would stare at me ‘dead fish’, and then with a sneer turn and ask the sister in charge (who always seemed to have the answer).
I realised after some weeks that there was a pattern to these formalities, a process based in a reasonably rigid hierarchy and the need to hold your place in the pecking order. I have never been good with rigidity and formality, but tried hard to be ahead of the game. The pressure was intense and constant; I hated it. I seemed to get support and sympathy from the nursing staff, including a couple of charge nurses who would attempt to prime me on what might be expected at tomorrow’s round, or try to mouth the answer during that day’s round.
I did get better at the game, but on occasion would fall down badly. There were regular nights of the week when I was rostered on call. I remember one week in which I clocked up over 140 hours, which included two separate nights where I was on the ward all night, had bacon and eggs with the nursing staff in the ward kitchen and then, unshaven and probably slightly sweaty, endured what felt like an endless ward round in which I was berated for not collecting some apparently crucial results from the biochemistry lab. I began to learn how to ‘use’ medical students. After all, they were just lower in the pecking order, and had much more time to ensure that everything was right as far as ‘their’ patient was concerned. I tried to be decent about it, but still felt like I was ‘using’ them. Stupid really; after all I had been in the same position only months prior and had survived.
On call was painful. Despite the fact that Jan and I lived only minutes down the road from the hospital the rule was that, on call twice a week, I had to be on site and sleep in the resident medical officer quarters. And it was severely frowned on to have a partner sleep in the hospital, even if you were married.
The accommodation was ordinary but fine and regularly cleaned, meals were quite good, and there was always a nightly snack trollied up from the kitchen late in the evening. Strangely, this brought the maximum number of medical staff together in a social gathering. We got to watch television when the day’s work was done. Of course if we were called back to the ward it often meant doing it at a fast rate. It was often an emergency. Then of course, from time to time I was called down to Casualty to review a case, but only if the registrar was busy elsewhere. Being a House Physician on the Professorial Medical Unit did not confer executive decision-making powers, even if I was known for having survived 6 months in Casualty and knew most of the staff. I was still the junior.
One section of the medical ward was given over to the beginnings of a major trend for King’s. One of the consultants Dr. Victor Parsons had a major interest in renal medicine, and was on his way to building a personal empire later relocated to Dulwich Hospital which, with St. Giles, had joined the King’s group in 1967. Peritoneal dialysis was fast becoming a way of assisting patients with acute renal failure. It had been used sporadically in the United States since the 1950s, but there were many complications including mechanical problems like obstruction of flow, leakage, and then more serious issues like peritonitis, perforation of viscera, abdominal haemorrhage, and adhesions. Treatment could be maintained only for a few days and, for it to be successful, all the mechanics had to be right. The idea was that an airtight sterile entry tube into the belly delivered a regular flow of at body temperature hypotonic fluids which covered the outer layers of the omentum and gut. Then there was an airtight exit tube. Effectively the surface of the organs leaked fluid and this was washed away. This leakage had been known about for a long time – the ‘ascites’ (the medical term for ‘dropsy’) connected with serious renal damage. The immediate advantage to patients coming to the unit was the relief of their own ascites which can often be very painful. The second advantage was the washing out of toxins from the blood stream across the gut and omental surface. Over a short time, renal patients would suddenly have a clear mind and be able to think. This in turn would encourage them to avoid ‘giving up’.
Of course, as you can imagine, the technology of the machinery had to be absolutely correct. Absolutely everything had to be done within strict sterile precautions. It was all new and, looking back through all the years, I can feel the tension that existed in the Unit, and fully understand it. Everyone was on trial. From my perspective, I was fascinated by the process, happy to accept the training, and overjoyed when finally I was allowed to replace (or at least assist the registrar replace) tubes if they got clogged in the middle of the night. I did not know that Vic Parsons and the unit were on trial. At that stage you have no idea of the politics and machinations, and the history-making side of what we were doing was never really explained to me. Ultimately it was to be successful, and the whole circus was moved into bigger quarters with extended facilities. Fascinating to have been there, even if I never really felt part of the program; simply a junior doctor who would move on to other things in a matter of months, and would not find out the importance of the whole thing until researching a life story almost 50 years later.
Of course not everyone was suitable for peritoneal dialysis. In addition, the process in the early days had strict time limits to avoid infection and internal abdominal scarring. There was a reticence to repeat the process too often, even if someone was at death’s door. There was one patient who stands out in my mind. He had been a senior physician in Sri Lanka for many years. He had travelled to the UK and King’s as a last resort to stave off renal failure. He had a series of peritoneal dialysis treatments, but it was never enough, and he had been taken off the program. The use of renal transplants, tissue typing, and medications to prevent rejection were still in their infancy. He knew his renal status was terminal, and chose to stay on the ward for his last weeks, often surrounded by family and former colleagues.
He was a charming and urbane man, and had endless stories from his early days in medicine. So whenever I could, often after visitors had left, I would sit with him while he reminisced, often for half an hour or so. I felt an immense sadness that this man’s experience and skill would all be lost as he faded. But it was more than that. I felt an affinity; I was just drawn to him. Perhaps I recognised that one day this might be happening to me; but looking back, that was far too philosophical for my younger self. I had not experienced the coming of death at such close quarters, but I don’t think that was the fascination. I just enjoyed being with him. I have a sense that he taught me some humility. I was deeply saddened coming in one morning to a ward round to be told he had passed away in the night. I did not weep, but I did feel an immense sense of loss.

Some months later, a rather large and very heavy box arrived at our flat from an unknown sender. Jan and I opened it to discover the most exquisite dinner service of hand-painted china. It is robust, and still in use 50 years down the track, not a piece broken through endless cycles in dishwashers. There was a card simply noting thanks from his family for my care, explaining how much my time spent with him had meant. I was, and remain, bemused by this kindness. I somehow felt that I was the one who had gained from the experience. He had been somehow a haven in the midst of the ward turmoil. And I believe it was he who taught me not to fear death, a lifelong and very special gift.

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