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The Path Before Us

As the coronavirus crisis has been looming, I’ve been on my surgery placement in Bury St Edmunds. Our placements last six weeks, and I’ve just finished week five now. Up until very recently, things had been pretty normal on the wards. I mean – things need to be. People still get appendicitis, bowel obstruction and flares of their inflammatory bowel disease whether coronavirus is lurking or not.

I don’t have much interest in surgery. I’m not dextrous enough, the training is way too long, and I don’t derive much pleasure from cutting things open. As a surgeon, you’re an intruder in the human body so your aim is to go in, fix the problem, and leave as little a trace as possible of you being there. Every moment your implements infringe on the anatomy, you risk irreparable damage. That pressure is a heavy burden to bear; one which, I think, I would struggle to handle.

All that being said, I did enjoy the laparoscopies. The skillset requirement is similar to competitive video gaming. You live-stream yourself to a screen in the operating theatre, control a mini robotic arm, and burn/cut/snip stuff (or a combination thereof) all whilst watching it on the monitor. It comes with emotional crescendos, dopamine rushes and a team of operating staff offering live commentary (“ew, that looks nasty” or “no wonder she was so ill”).

My achievement of the placement was holding the camera during the removal of a necrotic appendix. It was one of those rare, fleeting moments when you feel useful as a medical student. Just before the climax of the procedure as the surgeon was about to snip off the dead, gangrenous, vestigial piece of anatomy, bizarrely I had the fleeting thought that maybe I could become a surgeon. It’s a sexy job. However, as pus extruded from the stump abutting the caecum, I quickly came to my senses.

Over the past five weeks, I’ve seen some interesting pathologies, and on the whole, I’ve had a good time. The doctors at the hospital have been really supportive and as a final year you feel like your knowledge is really coming together, and you can immerse yourself as a team member with some valuable input. I also want to be a GP, so breadth is the name of the game and many problems you deal with as a GP are ultimately surgical ones. Plus, I think there’s value in having a GP who at least knows what the inside of an operating theatre looks like.

Looking back, it’s utterly bizarre how quickly things have evolved on the coronavirus front. At the start of the placement – from mid-February right up until the third week – the coronavirus threat seemed pretty small and distant. I was reading in the news about what was happening in Italy, but still, in my mind, I just didn’t think the same shitstorm would hit us in the UK. That’s partly because of geographical separation, but also because of some weird, deep-seated idea in my hindbrain that gives me the impression that we are somewhat ‘different’ from the Italians. I don’t just mean their sexier language or glorious olive-coloured skin: I mean an irrational idea about their biology. “It won’t affect us like it does them.” It’s a bizarre thought, but it lingers at the back of my mind.

Perhaps I’m being cynical, but wandering around the hospital over the last week I did get the sense, occasionally, that some people enjoyed the excitement that comes with an imminent and inevitable crisis. I especially noticed that some managers seemed to relish the prospect of ‘mobilising the troops.’

I remember one particular instance in a handover meeting where a manager came in and waved a sheet asking all the staff to fill in whether or not they have chronic medical problems. The idea is that these conditions put the staff at risk of more serious consequences should they become infected with coronavirus. “We wouldn’t normally ask for this information,” he explained, “but exceptional times call for exceptional measures especially with the coming apocalypse.” As he said this, he grinned ear to ear and it was rather disconcerting.

I have a theory about the proximity of threats. I’m sure someone has probably thought of this before… don’t you think it’s so hard to discover something new these days? Anyway, here goes. When the threat is really far away, interest is minimal (A virus in a Chinese market? Hubei who?). When it gets closer (like now), the excitement peaks: the full force of the tidal wave hasn’t hit yet. When shit hits the fan – around two weeks away if the news is to be believed – we get the despair.

proxthreat

Not sure whether this is blindingly obvious or rather profound.

Unfortunately, my own personal descent into anguish came in the middle of the week. We received another email from the Clinical School:

Students should continue aiming to finish this week of their last final year placement if at all possible…

So that’s it. Our placements were cut short. This was the final week. During medical school, I’ve been all over East Anglia. I’ve been to GP practices, A+E departments, operating theatres and psychiatric hospitals. I’ve seen flats that look like they’ve been taken out of Trainspotting, multi-visceral transplant surgeries lasting hours and doctors with the communication skills of a self-checkout machine. And it’s all coming to an end.

It’s the second time – after having our exams cancelled last week – where I’ve felt a profound sense of emptiness and a lack of purpose. For better or for worse, I derive a lot of self-worth from my work. I remember my grandma would tell me “there’s nothing worse than waking up in the morning and dreading the job you’re doing,” but I’ve taken that to the other extreme. My identity is so tightly interwoven with my profession that a threat to one inevitably becomes existential.

I’ll try and keep myself busy. Writing my thoughts down has always been an outlet and it’s more important now than ever. It gives me the opportunity to use my brain as a filter. I jot down all the different bits and bobs that have happened to me over the past few days, all the news and events, and do some mental triage. What’s worth remembering, and what isn’t.

Looking forward, us final years still don’t know what’s in store. Rumours abound. As far as I understand it, there are three options.

First option: rest. Decompress. From talking to friends who’ve been through the crucible of FY1/2, it’s impossible to appreciate just how stressful starting as a junior doctor is until you actually do it. It’s physically and emotionally exhausting. The hours are long, the work is intense and the stress levels are high. One part of my brain says “oh yes, it’d be very sensible to take some time to chill – invest in yourself – #selfcare.” The other part, probably also responsible for my restless legs, is saying “no, you couldn’t sit around for weeks doing nothing – get off your arse.” Taking a break is a skill which I haven’t mastered.

The second option is to volunteer – like a medical student militia. The thought takes me back to my school days volunteering in Manchester Royal Infirmary. We wore blood-red shirts with ‘VOLUNTEER’ plastered on the front in white letters. We aggregated in little gangs preying on poor, unsuspecting patients – “Are you lost?” “Can I help you?” “Um, I barely know what gynaecology is, let alone where, sorry.”

I suppose it’d bring my training to an end in a delightful full circle. Don’t get me wrong, I wouldn’t mind volunteering, but I think it would depend on what I was doing. For example, I wouldn’t mind being on the phone helping on NHS 111. In my imagination, I have a fanciful idea of what it’d be like. I’d be like an operator on one of those old-school switchboards – “Operator. What’s your emergency?”

In reality, it’ll be like the call centre from the BBC3 programme, innovatively titled The Call Centre. The annoyingly charismatic manager barks soundbites like “happy people sell,” but the reality is the poor staff are miserable and getting paid minimum wage. The highlight of the week is a night out getting bevvied, but thanks to social distancing, even that wouldn’t be allowed anymore.

combined pic

Left: my imagination. Right: reality.

The third possibility is that the General Medical Council expedites our registrations. This means we could start as junior doctors pretty damn soon. Erm… gulp.

Several of my friends are excited at the prospect, but it makes me feel uneasy. Who am I going to ask for help? The staff are being pushed to their limits, so will we have enough supervision? There’s not enough PPE for the senior doctors and nurses, let alone a whole new intake of junior doctors. So will we be protected? It’s probably going to be the most challenging time in the history of the NHS to be a newly qualified doctor.

In my spare time, I’m still flicking through the flashcards I made for my finals: what to do in acute heart failure, what to do when someone has pneumonia, how to manage the very sick patient etc.. I can reel off some of the protocols like the back of my hand, but I still feel woefully underprepared. How do I actually do all these things? It’s one thing being book smart but its another task entirely putting those skills into practice.

But these are exceptional times and they call for exceptional measures. I can mull things over in my head, and ruminate until I am replete with self-doubt. But when the time comes for me to start – whether that’s in August or sooner – I guess I’ll have to be ready. Confident, capable and assured in what I can do, but at the same time fully aware of my limits.

In the fell clutch of circumstance
      I have not winced nor cried aloud.
Under the bludgeonings of chance

      My head is bloody, but unbowed.

Invictus, Verse 2, William Ernst Henley

 

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