Bed­lam in the ward

The Weekend Australian - Review - - Books - Karen Hitch­cock

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

young doc­tors

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