A response to Medicine Unboxed Voice 2013
I was 17 years old, working as a health care assistant on an elderly care ward at Winchester hospital in 1988. I remember a morning shift when I was responsible for helping six patients get washed and dressed. No matter how demented or unaware of their surroundings, we wanted every patient to be properly dressed and “sat out”. Maureen was 81 years old, suffering from Alzheimer’s disease, her confusion compounded by a recent stroke and a urine infection. She was lying in bed, calling out, “Na! Na! Na! Na! Na! Na! Na! Naaaaaa!” I pushed my trolley with a bowl of warm soapy water, wipes, fresh clothes and clean linen up to her bed and pulled the curtains around. I squeezed her hand and said, “Good morning Maureen, I’ve come to help you get ready for the day”. She looked at me and continued saying, “Na!” I pulled back the sheet and saw that she had managed to pull off her padded incontinence knickers, faeces were all over the sheets, down her legs, up her back all the way to the nape of her neck and in her hair. She seemed completely unaware. I had been working on the ward for a month and was used to bodily fluids, but the smell still made me retch. I quickly stepped outside the curtains as my mouth filled with saliva and my stomach tightened. I concentrated on my breathing for a minute and went back inside to see Maureen holding her faeces-covered hands in front of her face. I grabbed a cloth and without having time to put on gloves or an apron, wrapped it around her hands. Instinctively she snatched them away – she shocked me with her strength and left my bare-hands covered in brown slime.
Eventually, she was sitting in the chair beside her bed, washed and dressed; it was 8.30am. I had another 5 patients to go. As I pulled back the curtains, I heard an unmistakeable squelching sound and its accompanying smell. Perhaps, I hoped, I was mistaken. Other patients were lying in soiled sheets and incontinence pads, calling out for help, or too confused or weak to call. Briefly I looked at Maureen, my bag full of soiled cloths, the bowl of tepid dirty, soapy water and the clock on the breakfast trolley, slowly cooling porridge congealing. Should I pull the curtains around again, start all over again? Keep the other patients waiting? I didn’t know, I really didn’t. I closed my eyes, gritted my teeth and I moved on to my next patient.
Eight years later I was 25 years old, working as a casualty doctor in Greenwich. It was about 2.30am, there were perhaps 12 patients waiting to be seen and the time between arrival and my assessment was about 3 hours: about average for that time of the night. The call came out on the PA to say that a serious trauma call was coming in by ambulance. I made my apologies to the tearful young woman who was having a miscarriage and ran to the desk. It was only my fifth day as a junior casualty doctor and it was my first trauma call. The nurse in charge took me aside. She explained that the three young women coming in were already dead, killed in a car crash. It was my job to certify them. All I had to do was go into the ambulance and check their vital signs. I remember standing outside in the icy february night. My heart was pounding in the back of my throat when the ambulance pulled up, blue lights on, siren off. The doors opened and one of the paramedics held the door open. I climbed in. It was the first time I had ever been in an ambulance. I can only remember one of the faces, or perhaps so long after the event what I can remember is an amalgamation of all three. She was the same age as me. Her face was grotesquely twisted, like her unbroken face might have looked like an hour ago, reflected in a broken mirror. Micropore tape held her jaw and temples roughly straight. Her eyes were wide open, each staring, frightened, in different directions. Certification of death meant shining a light into her eyes and listening to her heart and lungs. Kneeling down, praying or sobbing all seemed more appropriate. I performed my duty, solemnly, terrified, utterly unprepared. I walked back into the department, straight into an angry relative, demanding, drunkenly, when – the fuck – I was going to see his wife.
This week aged 42, I finished my morning GP duty session at 1.30pm after taking 53 calls from anxious patients, seeing 10 patients face-to-face and doing one home visit. I sent one woman to hospital with an infected knee, spent 30 minutes with a man who since his teenage daughter was diagnosed with schizophrenia has lost his job, been arrested for drunk driving and bought rat-poison with the intention of suicide, and stopped half the regular prescriptions for an elderly woman who told me she wanted to stop postponing death. I was just about to slip out to get some lunch when the practice manager called to ask if she could speak to me urgently, one of my patients had complained about me and had written to the local newspaper, the MP and the parliamentary health ombudsman. I opened my door to find one of our trainees waiting outside – “Please can you help me?” she asked. My next session was due to start at 2pm, there were 15 patients booked in, I had 43 blood results to check, a boxful of hospital letters, and a message from a social worker about a patient that was expected to die. I hadn’t had anything to eat or drink, or even time to pee since I left home at 7.15.
Work like this constitutes a normal working day for health professionals, but at the same time it is completely abnormal. To do this, and to engage seriously, compassionately and with full attention and moral seriousness demands what Iona Heath has described with eloquent passion as a “Labour of Love”. It is emotional labour. If we expect healthcare professionals to treat care as a vocation and patients with empathy and compassion, we need to appreciate the enormous burden of patient-centred care. We must treat carers with the kindness and respect we expect them to treat their patients. We must make time to help them give the personal care their patients need and time to listen to them. We must listen to their concerns, their doubts, fears and distress.
Not a day goes by without someone in health policy or politics claiming that the NHS has put professionals before patients for too long, or that public service propagates professional complacency or that the threat of competition or prison is needed to improve care or compassion. These claims are profoundly depressing and so far removed from my experiences of 25 years of personal care, so insulting to all the dedicated, caring professionals I’ve worked with, and so, so wrong for patients.
Menzies Lyth, the emotional labour of care and social defences, blog by Richard Smith
How do you care? Wonderful blog by a nurse about how she cares for elderly paitents.
A child’s tragic story ended my nursing career. Guardian Feb 2016