Bedlam in the ward
WHEN I was at medical school everyone was reading Samuel Shem’s satirical novel The House of God. They’d carry it around with them, quote from it, laughing. The novel, written under a pen name by American psychiatrist Stephen Bergman, tells the story of Roy’s first year as a doctor. Roy works in a large city hospital devoid of all order and humanity. Elderly patients are called GOMERS, which stands for Get-OutOf-My-Emergency-Department. He’s taught the rules by Fat Man, a senior registrar. Rule No 1 is: GOMERS don’t die. The book offers a picture of medicine raw with inhumanity. Rule No 9 is: The only good (patient) admission is a dead admission.
The junior doctors spend their time panicking, avoiding work, harming patients through over-treatment and trying to survive long periods of sleep deprivation. Cynicism sets in early. Roy walks to his outpatient clinic with “that sinking feeling of having to deal with these husbandless hypertensive LOLs in NAD (little old ladies in no apparent distress) with their asinine demands for my care”.
First published in 1978, The House of God continues to sell in the tens of thousands. Some medical schools in Australia give copies to all their students as a graduation present. Horrified, I made it only through a few chapters before I started begging everyone to throw it away and read Anton Chekhov or Mikhail Bulgakov instead.
Medical memoirs are everywhere; they have been for centuries, since Galen and Hippocrates. As American writer Terrence Holt puts it in his introduction to Internal Medicine, a collection of stories documenting his first year as a doctor, “The hunger to get behind the scenes of institutions that keep their inner workings hidden is powerful; this is especially so around medicine.”
Holt’s case studies illustrate the constant anxiety he felt throughout those first months on the ward. “I’m standing in the middle of this roar and babble. My pager is going off more or less continuously. The phones are ringing, the unit clerk is crying out names (one of which, if I could only hear him, might be mine) to come and take a call. There are visitors, family members, and patients leaning over the counters, each with some question, need, or piece of information. From time to time the hospital PA system adds to the din … I looked out over this scene and said to myself: This is not narratable.”
He writes with unflinching honesty about all the fears, joys and brutalities of a junior doctor’s work. Some of the stories are difficult to read. In one story, A Sign of Weakness, he spends an en- Internal Medicine: A Doctor’s Stories By Terrence Holt Black Inc, 288pp, $27.99 Falling into the Fire: A Psychiatrist’s Encounters with the Mind in Crisis By Christine Montross Oneworld, 256pp, $27.99 Riding a Crocodile: A Physician’s Tale By Paul Komesaroff UWA Publishing, 374pp, $26.99 tire night fighting and forcing a woman who is dying of an irreversible lung disease to wear a high-flow oxygen mask she finds intolerable. As a result of his insistence on maintaining her oxygen levels — rather than giving her medicine to ease her symptoms — she spends the last hours of her life in torment, drowning.
In the best story in the collection, A Perfect Code, Holt describes two cardiac arrests and the emergency team’s attempts to resuscitate the patients. The first is a typical ‘‘code blue’’: a room full of doctors and nurses taking blood, sticking in lines, cracking ribs with chest compressions, shocking the patient, injecting her with adrenalin, yelling orders no one hears. “What a mess,” he thinks as he leaves and smoothly gets back to his other jobs, having declared the patient dead.
The second case is textbook perfect: it runs quietly and smoothly. “Mr Gillet had coded, coded beautifully, and he had survived. We had done everything right.” They restart his heart, but he never wakes up and is dead five days later. In this story Holt has narrated what he felt was un-narratable: taken us into the chaos and shown how perfection may not equate cure.
For a doctor, reading a book that describes the inner workings of a hospital in detail — a place we know well — can sometimes feel like work. It also can be frustrating, as when it takes Holt a week to realise the patient he thinks is ‘‘in denial’’ about his new cancer diagnosis is in fact severely (and obviously) demented.
Reading the highly detailed descriptions of the internal workings of the hospital in Riding a Crocodile, a novel by Melbourne doctor, philosopher and writer Paul Komesaroff, also often felt like hard work to me, a clinician. This is an unusual book: a high-camp satire spliced with a textbook of biomedical ethics. It follows Abraham, a hospital physician, over two months of inpatient ward service. We watch him diagnose patients, teach students, mentor junior doctors. He holds his clinical and interpersonal skills in
The emergency room
can be a source of drama and horror for