When a photograph of an emergency room doctor grieving for a 19-year-old patient was posted online recently, it went viral with thousands of shares, likes and comments. Most of this stemmed from the fact that doctors are not known for showing personal emotions. Like all healthcare staff we deal with difficult, sometimes hugely distressing scenarios every day. We have all had moments like that doctor. Where a patient has affected us so profoundly, we cannot hold it together and need some space.
This is a tribute to just five of the patients that have taught me to be a better doctor. Identifying details have been changed to preserve patient anonymity.
* * *
Malcolm was the name of my childhood GP. When I arrived at medical school, and met the male corpse I and my nine colleagues would dissect to learn human anatomy, we decided to give him a name. Malcolm won. Dissection was one of the things I had been looking forward to when I applied to medical school - for a budding doctor it doesn't get much more morbid yet simultaneously fascinating.
Malcolm taught me so much. He taught me how not to vomit when I see things that make me want to. He taught me that it's easy to miss the oesophagus in your first week and accidentally put it in the waste pile. He taught me the start of the dark, strange sense of humour that doctors have to have to survive. He taught me you can't wipe the smell of formaldehyde off your anatomy textbook when it's been in the lab for too long. He taught me that, at some point, another doctor had made enough of a difference to him, for him to donate his body for us hapless ham-fisted undergraduates to cut up. He taught me all the millions of names of parts of the body that I had to sit and memorise for nightmarish anatomy vivas.
After a year of cutting him up, two years after he died, we finished our anatomy course. I and my group went to his funeral. We sat in the crematorium while an unknown minister said a few words about a man none of us knew. We found out his name then - needless to say it wasn't Malcolm. And he taught me what death looks like, as we watched through the window in the crematorium furnace while the body we had learnt and practiced on was turned into ash. Malcolm's family didn't come. Some of the other groups got to meet their "body's" loved ones - to shake their hands and thank them in person. I didn't. But I didn't forget him and everything he taught me. And I will be eternally grateful, as will all my patients since, because as well as teaching me anatomy, Malcolm taught me gratitude.
* * *
I was a third year medical student, on my first clinical placement. He was an elderly man, who arrived with a concerned daughter. The history was vague: losing weight, non-specifically unwell. The Consultant asked a lot of questions. When he examined the man, I stood quietly next to him. Watching, trying to remember the correct way to feel the abdomen, worrying in case he asked me a question. "Would you mind if my student has a feel?" The patient agreed with a smile. So I felt his abdomen, and guided by the consultant, I felt his liver. It felt hard, rough, like a collection of marbles. It was easy to feel - I felt relieved not to have missed it. Then I realised what that meant.
I sat silently while I watched the consultant break the news. His words were kind, like the patient who hadn't minded that I had intruded on his appointment, and prodded around his stomach. I remember thinking "I'll never forget this man, his name - my first cancer diagnosis". But I did because there have been so many since. While I have not forgotten him, I have forgotten his name and for that, I will always feel guilty.
* * *
As a newly qualified junior doctor, working on the busy admissions unit, I had seen a constant stream of patients. My job was to take the history, examine, and find the more senior doctor with a management plan. When I pulled back the curtain, I saw her laid there. An awful, yellow colour, thin and frail. Next to her was her husband. They were both young, but looked old. I took the history from him - she didn't stir. She was young. In her thirties. She had three small children. She had been diagnosed with cancer 18 months ago. She had waited to go to the doctor, worried about what the lump meant. And when it was confirmed to be cancer, she was terrified.
She hadn't wanted treatment to make her hair fall out and upset the children. She hadn't wanted to have surgery and be away from them while she recovered. She had turned instead to homeopathy. And someone, somewhere, had treated this woman with terminal cancer with water, and told her she would get better. And she believed them. By the time I met her, it was too late. She was dying. She hadn't wanted to come into hospital but her husband couldn't care for her at home. I gently examined her wasted body. Then as I prepared to find the senior doctor, he asked me: "Can you make her better doctor?"
I didn't say no. But I did say we could make her comfortable. We could find her a side room with some privacy, away from the busy ward. We could let her family come to see her whenever they wanted. He cried, heartbroken, and said he knew she was dying. There seemed no point in berating him for letting her choose a treatment that was no treatment at all. I didn't know them. It would have made no difference. When I came to the ward the next day, she was gone. She had died overnight, in a side room, with her husband by her side. That was all we could do. Whenever I am asked my opinion of homeopathy, I remember what this woman, and the look on her husband's face that night.
* * *
Working in A&E was a baptism by fire. I had done some medicine and surgery since qualifying, but had little experience of trauma and orthopaedics. It was my first weekend there, working with doctors I didn't know. By now I was training to be a GP - "just a GP trainee" as I was frequently referred to. I dealt with a lady from the ambulance crew. She'd collapsed at home and come to the hospital. She was awake, talking, with her concerned family there. I took her details, examined her, and thought her heart was the most likely culprit. I had to wait for more tests to see if she'd had a heart attack. I did an ECG (heart tracing). The heart wasn't beating in a normal rhythm. While she sat up chatting, I took my notes to the senior doctor on duty.
"No it's not her heart, probably just a faint."
"But the ECG is suggestive of..."
"No, just do another ECG and move her into a normal bed."
I duly went back to the patient, did another ECG, which was normal, and asked the nurses to move her out of the observation area. I went to my next patient. Half an hour later I heard the scream from across the department - her relatives shouting for help. She had stopped breathing, her heart had stopped. What I had seen on the first ECG was a heart problem. I had been right. We resuscitated her for almost an hour. We called the Intensive care consultant. I cornered him as he wrote his notes up, trying not to cry. Was I right in my diagnosis? Yes. If I had kept her in the monitored bed, would this have happened? Possibly. Would her outcome have been better? Yes. I asked to come with him, to speak to the family. They listened, numb, as we both explained she had suffered too much damage to recover, and they should prepare themselves for the fact she would die soon.
I stepped outside in tears. This was my fault. If I had stood up for myself, been more confident in my diagnosis, she would have stayed more closely monitored. A nurse would have been right there to start treatment. The Intensive care consultant was philosophical. He told me it would probably have made little difference to her outcome, but that the next time I disagreed with a senior doctor, I should remember this lady. "Just because another doctor is above you, doesn't mean they are always right."
* * *
Calls to the labour ward as a doctor in paediatrics can mean anything from an emergency caesarean to a baby needing a blood test. The midwife said a lady had arrived in quite advanced labour, there was little history, would I mind attending the delivery just in case?
I stood quietly in the corner of the room, waiting for mum to deliver, checking the equipment that most of the time I simply packed away again when the baby emerged crying and healthy. When I heard the midwives asking mum to pant, I knew she had nearly delivered. I watched the monitor. Baby's head came out. And stopped. I waited, watching the midwives. A few more pushes, and it became apparent this baby was stuck. The midwives acted quickly, well drilled in this scenario. Emergency buzzers sounded. More midwives came in. The on-call doctor for the labour ward arrived. And I watched the clock. I knew that each minute that went by made the situation ten times worse. I checked my equipment again, watching anxiously as the heart rate monitor started showing dips.
As the atmosphere became more and more tense, as the midwives and obstetric doctors tried more advanced techniques, I watched the clock.
At five minutes I was panicking.
At seven minutes I felt sick.
At nine minutes I suddenly realised despite all the doctors and midwives looking after this baby and its mother now, when it was finally born, I was currently the only one who was there just for it. I would be handed the baby whose heart rate monitor now barely registered. The first step in resuscitation is to call for help - I had stood so horrified by the events unfolding I almost forgot. In the middle of the chaos I asked for someone to crash call my registrar. A minute later I was handed a baby who was not breathing, had no pulse and was grey. Almost without thinking I started the steps I knew so well - dry vigorously, assess, rescue breaths, assess, start chest compressions. Although the midwives were all experienced, they were shell-shocked having witnessed such a dreadful delivery. I could see them looking at me expectantly as the minutes ticked past, and I kept on doing the breaths and the chest compressions over and over with no improvement. I've never been so glad to see another human being as when my registrar walked in. Never been so glad to step aside for a senior doctor that I knew I could rely on.
We worked on this baby all afternoon - it died the next day. I will never, ever forget that baby. It taught me how fragile life is. How cruel it can sometimes be. And how, in the middle of that delivery room, there was no place for the midwives, the other doctors or me to show our own feelings. Because that, and all the other times that I have struggled and learnt, are about the patient; about them and their family. Not about me.
I am there to do my job. I am there to help. I am there to be a doctor. So I will go outside, sometimes by myself, sometimes with a colleague, and afterwards I will cry like the doctor in the photograph. Then I will pick myself up and carry on. There is always another patient to be seen. And to learn from.