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Thursday, October 20, 2016

Making of a Child Psychiatrist: (53) Moving towards General Practice (2)

My last day of working at King’s was 20th September 1969, and we were due to move into the flat at Margate General in mid October ready for me to begin work.  Our little East Dulwich first family home had to go back on the market to make us a small profit and pay off the bank. The in between was a flurry of activity, sorting furniture and transporting it down to Kent in a van driven by my brother in law Jim, husband to Jan’s older sister Wendy. Luckily the summer seasons at Kingsmead were over, and Jan’s father had begun to convert the hotel into apartments. So there was temporary storage space for our belongings as well as us. I know that Jan’s parents, having always been family oriented people, were utterly delighted we were moving to Kent and would be living and working just up the road. Jan was delighted to be coming home, even though she had been forced to give up her job with all the respect it gave her as a professional. We created upheaval, but nobody seemed to mind. I guess that is the wonderful thing about family life.
We also had some family news. Jan had missed several periods, and was certain she was pregnant, with our new family member due in early April. So everything was new and full of promise. We no longer had a house to call our own, but that could be organised during my time at Margate.
One of four in the block, our ground floor flat was functional, sparsely furnished in a simple utilitarian way, and it had its own small fenced garden and a car park.  Jan did not enjoy it. Perhaps it was not ever to be a part of ‘us’. She was pregnant, and it was too empty and clinical to ‘nest’. Unfortunately there was also a constant smell of curry permeating the entrance hall and our flat. Both Jan and I love a good curry from time to time, but the couple of doctors upstairs were from Pakistan, and so curry seemed to be on the menu every day. Add in Jan’s pregnant state, a hyperawareness of smell, and my absence during working hours, and she preferred to be elsewhere. The problem was that she did not yet drive confidently and independently, so she had to catch the bus into Westgate to be with her parents or with an Auntie Kate, who was to be very supportive over many years.
The entrance to Maternity was a short 100 metres away from the flat. So I was able to get back to the flat for lunch when Jan was there, and was also home early after work, even if it was a bit too convenient for staff in need of a doctor urgently – even when I was not on call.
The Director of Obstetrics was Dr. Jean Burton-Brown (‘Miss Burton-Brown’, as she was known), who came from an august family of eminent surgeons who had served England and the Empire over generations, with a great grandfather in the Bengal Medical Service, a grandfather who was a Brigade Surgeon in the army, and a father who had been a surgeon in the navy. She had qualified somewhat late at the age of 32 and been a doctor during the London Blitz, gaining her membership of the College of Obstetricians and Gynaecologists in 1944.
She had an immense reputation for her gynaecological and obstetric work in Kent where, for over 20 years, she had developed the services against the odds, and overseen the building of the Maternity unit. She was highly esteemed by nursing staff who were certain she would always be there to back them up. But I suspect that when I joined the staff in 1970 (when she was only three years away from retirement), she had had her fill of jumped up young men who knew very little. She had high expectations, could be dictatorial if you did not listen, did not follow protocol or were a bit uppity. She could be scathing, and in the early days I came in for several dressings down when I had not completed a task to her liking or to her standards. I learned rapidly to toe the line. Luckily, given my experiences in Plymouth and at King’s, in the day to day business I was always ready to learn from nursing staff, and not embarrassed to get something checked out. I was also happy to refresh my obstetric knowledge through my ever present Brudenell textbook. Given my past experience of surgery, I don’t know how I would have managed as her Gynaecology house officer. But, Obstetrics is almost always a happy process with positive outcomes, despite occasional human interference. So although there were clinical panics from time to time, the staff were a happy constructive lot, and the 6 months from the work point of view passed very happily.
In retrospect, and although I would not have been conscious of it at the time, I am certain that my psychiatric experiences played a role. Most births are not traumatic in a long term sense, but if things begin to go wrong, the possibility of lifelong trauma is a serious issue. I knew that people survived trauma much better if their anxieties could be soothed. So there were several pregnancies that just did not want to go into full-blown labour, despite hours of waiting and special drips. Sitting, listening to life stories, soothing anxieties and keeping a positive demeanour certainly did no harm, even if you could not measure the good. Sitting with, and listening to, anxious or angry husbands who were demanding action where none was appropriate, seemed to help everyone. It was a form of abreaction without the use of Ether or intravenous injections. I was often threatened with violence because I was somehow seen as responsible for a circumstance. “You’re the doctor; you should be doing something!” But although there had been stories bandied about, violence to person or property did not occur during my time.
I found myself having the most ordinary of conversations while masked and begowned, completing necessary sutures. Similarly on two occasions, I had to complete manual removals of recalcitrant placentas. Here you are doing the most odd procedure, and listening to the most ordinary of discussions about the future plans for a woman and her new family.
I was never to be in charge of a caesarean section, given my youth and inexperience, but I was always happy to assist. In those days it was not a lifestyle choice, it was an emergency procedure to save the lives of both mother and child. They were such joyous occasions, and there was always that sense of having beaten the odds.
Our second child was due to be born in the maternity unit on 6th April. The issue was that if he was born prior to April the 5th, we would recoup a whole year of tax. So what, I hear you say. Never muck about with nature. Just let life take its own course. We discussed it again and again. We certainly could do with the money. The word from several of my midwife friends was that a dose of caster oil would create strong bowel movements, and that this in turn would prompt labour if Jan and the baby were ready. We decided to take the risk on 31st March, and with a mix of excitement and concern Jan swallowed her medicine.
Early the next morning, we both woke to an audible thump, and Jan had a strong urge to go to the toilet. Within minutes, there was a cry of need from the bathroom, and Jan announced she was in labour and frightened she would deliver down the toilet. We moved her step by step back to the bed and gathered her ‘ready’ bag. I raced across the tarmac into Maternity, grabbed a wheelchair, and charged back to the flat. We then raced back up the slight incline, through the doors and down to the delivery suite where our Roderick was born about 20 minutes later – our April Fool son, apparently no worse for his precipitate journey. So the whole labour was about 45 minutes from ‘thump’ to a newborn’s cry. I was so glad I was working in the unit, so glad we had a flat so close, and so grateful to the midwives at 6.15am on April 1st. I wished we had not challenged nature. There is always a cost to such manipulation.
Part of the cost was that Jan had a slight perineal tear, which may have been avoided if the skin had had time to stretch. I phoned Jan’s consultant, an older man usually very amiable. He refused pint blank to drive all the way from Canterbury at that time in the morning just to do a few stitches. Suggesting that I had had loads of experience and should do it myself, he put the phone down. I was appalled, and just could not bring myself to do something that I felt was not quite right. We organised one of the nursing staff with some prior experience and I supervised the process, still seething. Jan was to stay on the unit for the next 10 days, in part because that was the routine, but also because Rod became quite jaundiced after 2-3 days, and his bilirubin levels rose to the kind of levels the paediatrican thought might need transfusion. Luckily I had followed protocol and taken a sample of cord blood. So we were prepared. Jan was advised to give up the attempt to breast feed because there might be a sensitivity to breast milk. She had been so keen, and was deeply saddened and somewhat affronted. Rod stayed in neonatal intensive care for several days under bright lights, on a drip, and wearing eyeshades to protect his eyesight. He was to have food sensitivities throughout childhood.
There was a grand sense of closure to my six months, and Miss Burton-Brown took me aside about a week before I finished up. She actually thanked me and showed a faint smile; I have to say I was immensely grateful for her tutoring. However, she had to have the last word. I was going up to London the following day to do my Diploma in Obstetrics exams. I had been growing (what I thought of as) a very hip young man’s beard since my time in psychiatry (don’t all psychiatrists have beards?) She had told me on several occasions that beards were filthy things, harbouring germs likely to infect pregnant women and their newborns. She had never reached the point of demanding I remove it, but certainly had maintained the battle line. She told me forcibly that if I tried to do my Dip. Obst. with a beard, I would be failed. I asked her if she was serious, and she repeated herself, turned on her heel and stalked off. The following morning I shaved off the beard, but felt quite denuded throughout the journey. I attended the College, wrote the paper, had my oral examination, and that evening returned home feeling I had probably done fairly well. The following morning I began to re-grow my beard.

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