Skinner’s arm

I promised here a story of a performing lady and her abdominal scar. Here it is.

The year is 1973, the place south London. The time is Friday evening, and the story concerns four young men attending King’s College Hospital Medical School who were taking an evening stroll. As they proceeded from Camberwell in a north-westerly direction towards The Oval, a thirst descended upon them somewhere in salubrious north Brixton.

Behold, seest thou yonder hostelry?
Yea, verily. Let us thither hie to slake our thirst.
Aye, aye. Come, make haste.

It was—you’ve guessed it—the Skinners Arms (there is no information concerning whether or not there was an apostrophe, and if so where it went) on the corner of Vassall Road and Camberwell New Road. According to Wikimapia it is no longer in existence, having doubtless succumbed to town planners. Anyhoo … the four knights did enter.

If it be thy pleasure, fair serving wench, we parchèd wanderers each desire a tankard of thy most toothsome nectar.
Most certainly, wandering lords, quoth she.

Some time and several flagons later, behold the lights did dim. Music rang forth and lo, a performing lady materialized on the podium. This surprised the knaves. Nevertheless, they steeled themselves to witness a spectacle. The performing lady, they were astonished to see, gradually divested herself of her habiliments until she stood before the assembled company wearing only a two-piece bikini. She had a midline scar below the umbilicus.

Ah, comrades, espiest-ye the scar? Perhaps the lady hath undergone an hysterectomy.

It was not that the utterance itself was foolish, but rather the volume at which it rang forth, for the intended whisper cameth more as proclamation. If thou understandest that, thou dost apprehend the nub of the issue.

Thou art mistaken, fair friend, quoth the lady, for ‘tis an appendix scar.

And having uttered those very words the bikini-clad performer hied herself to the bench at which the knaves were seated, and sat on the knee of one of them, and polished his spectacles with one of her removèd garments.

Now, the knaves were, admittedly, junior medical students, but they possess’d enough knowledge to know that appendicectomy does not normally require a midline incision in the lower abdomen. Nevertheless, they sensed that circumstances were not propitious for further discussion of the issue. They felt that discretion was in their best interests, and without further quaffing or quoting they legged it onwards, returning to their lodgings to prepare for the rigours of the weekend. The young men were lucky, methinks, not to be set upon by the lady’s supporters.

The moral of this story? To draw conclusions from observations is good, but any proclamation of the same should be timely rather than immediate. The youth learnt a lesson.

Every sinner has a future, and every saint a past (Cardinal Hume, I think).

The south London children’s hospital again. Another story that does not reflect well on me.

Admission from Casualty. Young lad, about 6. A few bruises and a couple of broken bones. Once again, his name and his face are etched upon my memory. I shall call him Jason. A suspected battered ‘baby’ (the term used at the time). I examined him as best I could. He was apprehensive, watchful and suspicious of me. His father later came to visit as I was tending Jason in the glass-walled cubicle. I could hardly bring myself to speak to him—it would only have been ‘good evening’ anyway—and I could only just stop myself launching into a tirade. Fortunately I managed to control myself. Weeks later I was called to Camberwell Magistrates Court to give evidence, my first appearance in a court room. It was curiously low-key and inconclusive. I remember few details of that, other than that it happened. Not long afterwards, my job ended and I moved to Nottingham to become an Assistant Lecturer in Anatomy.

I assumed the parent(s) were guilty. They may not have been. Perhaps, as in one of Alan Bennett’s Talking Heads monologues, the child bruised easily because of leukaemia, and/or had brittle bones. I am ashamed of my rush to judgement. I was very young and our daughter was about 6 months old at the time. I worked a two-in-three rota, and was home only every third night.

Please don’t underestimate the emotional pressures on doctors, young doctors especially and those working with children in particular. I can say that the emotional pressures on pastoral clergy are similar, though less intense. This experience, and many others, make me pretty sure that it is just not possible for a sentient human being to be ‘neutral’ about anything, Our own experiences colour what we see and hear and how we think and react, and our emotions cause us to do extraordinary things, some of which we will regret.

It’s called being human.

Another story from the south London children’s hospital. It doesn’t reflect well on me.

It was a lovely balmy summer evening in 1976 (remember, dear reader, that I qualified as a doctor in June 1975). The air was scented with the sweet odour of traffic fumes from the adjacent A3 and A23. The occasional subterranean rumble signalled a passing Northern line tube. Passers-by gaily shouted greetings to one another as they merrily made their way to the Skinner’s Arms on Camberwell New Road for an evening’s intellectual exchange over a pint of golden nectar. [Sorry to intrude here, but I’ve another story about the Skinner’s Arms that could be told. It involved a performing lady and her abdominal scar. Maybe another time. Back to the plot]. The day was ended, ward rounds, theatre sessions, drips inserted, consultants humoured, parents talked to, emotion drained. I was the only doctor in the hospital, and I’d gone to bed.

In about the 40th hour of a continuous shift lasting three working days and the two intervening nights, the phone rings about 11.30 pm. It was the night porter.

Go to A and E, there’s a child in distress.

Indeed there was: a boy about 8 years old. He’d been stung by a bee (maybe a wasp, but the blog title wouldn’t be as good) that morning, and the resulting inflammation was bothering him. I tended the child as best I could. Painkillers, emollient cream and so on. Then I made my big mistake. I said to mama:

I’d gone to bed. I’ve been on duty for over 36 hours. Why have you waited till now to bring your little darling [well, I didn’t say that, quite] to hospital?

The mother, who worked as a nurse in St Olave’s Hospital, elsewhere in London, was outraged. She blustered:

I won’t be spoken to like that.

She obviously felt guilty and was embarrassed. She continued:

I wouldn’t be spoken to like that at St Olave’s.

My turn now.

Then you’d better go there next time.

And off she and the heir apparent stomp.

The moral of the story? There are several. They include (1) take your complaint to the doctor before the crepuscular fall in endogenous corticosteroids makes it worse; (2) remember that doctors are human too; (3) choose a hospital that is properly staffed by doctors rather than administrators. If you can find one.

Holy Wisdom

In 1975 and 1976 I worked as a junior hospital doctor in a children’s hospital in South London.

Once upon a time, in 1975, Simon (not his real name) was born with congenital biliary atresia. Liver damage meant that he would not see five years of age, and surgery at that time was ‘experimental’. Simon had repeated operations. I enter the scene in April 1976, a fairly newly qualified doctor, right at the bottom of the medical hierarchy. I am the first on-call doctor to carry out the consultant’s wishes during the day. I perform hands-on procedures such as intravenous drug administration. I am on call for two out of every three nights and weekends, at which times I am the only doctor in the hospital. Simon requires attention, often lengthy, during the small hours most nights. He has drips inserted into scalp veins. These frequently become displaced or blocked, causing swelling, inflammation and infection. It is my job to re-insert the drips into one of the increasingly few veins available. Simon is jaundiced, conscious and whimpering while this is going on. The memory of his large eyes looking at me as I am causing him pain is with me 37 years later.

During the next few months Simon has two further abdominal operations, a total of five so far. Sotto voce discussions during ward rounds acknowledge that Simon will die, but that perhaps another operation should be attempted. Face-to-face discussions with parents (Simon is their first child) are less realistic, or more upbeat, depending on your viewpoint. His parents are perplexed, distressed and uncertain. After the last operation I say to the consultant—remember I am the lowest of the low on the medical food-chain, ‘wouldn’t it be best for him and his parents if he were allowed to die with as much dignity as we can provide and he can muster?’ I am ridiculed and condemned for my views. My reasoning that this would have allowed his parents to begin to pick up their lives, grieving as necessary, and try for another child, is simply not heard. Simon undergoes hepatic surgery for the sixth time. A few days after this, Simon dies about 20 months old. This story is accurate inasmuch as my memory is reliable, long-forgotten details surfacing as I type.

Here are some of the issues raised by this story:

• Best interests? Whose? Simon, parents, society, doctor?
• How is unnecessary surgery justified? How can we know it’s unnecessary until it’s been tried?
• To what extent do doctors put the needs of research and career advancement before those of patients?
• Practising surgical techniques on babies for the possible benefit of those in the future.
• My advocacy of allowing the child to die could be interpreted as advocacy of killing (Dr Leonard Arthur at Derby in 1981).
• The effects of illness on the family, and the role of the medical profession in prolonging this.
• Difficult treatment and practical procedures being in the hands of the least qualified (me).
• The effect on me of being left to deal with Simon and his parents, especially at night.
• The role of managers and senior medics in not providing adequate training and support.
• The expense to the community of keeping alive, and providing expensive surgery for, those with no prospect of even medium-term survival.
• Giving information to relatives: the balance between providing hope—that is, probably telling lies, or giving straight facts.

Was it arrogant and presumptuous, evil even, of me to want to leave Simon to God, or nature if you prefer, with only compassionate care? Was it selfish of me to want fewer disturbances at night? As a result of Simon’s needs, I was less well-rested for other patients. Is it appropriate that Simon’s parents were not consulted but were told what would happen to him? The relationship between the ‘healer’ and the sick should be open and honest. In this case, it was not. I was constrained by the instructions of bosses and did not have the courage to disobey them. I was feeling, though not acting, as if I alone knew the mind of God.

How do we weigh the needs of the individual against those of community and colleagues? We have to make judgements, although to do so today is often condemned: ‘to defend distinctions of value … is to offend against the only value-judgement that is widely accepted, the judgement that judgements are wrong’ (Roger Scruton).