mortality

Tired. Slept well last night but still tired. I keep thinking that I could have something wrong with me.

As a doctor I try not to be a hypochondriac but I know too many people who have developed serious illnesses at my age. Leukaemia, lymphoma -  both can make you tired, although eventually some sort of lump will appear. Two of my mentors died of a stroke at about my age, not that there is likely to be much warning of that.

You see a lot of illness and death as a young doctor, but I first saw a dead body when I was eighteen. I had just proudly gained entry into a medical course and I wanted some money for a holiday, so my father arranged a job for me as an orderly at the cancer hospital where he worked.
I suppose there wasn't a great need for my services. Perhaps the job was more a favour to my father. In any case I was placed at the front entrance of the hospital. My job was to meet the new arrivals and escort or wheel them to their ward or clinic.The head orderly had been a porter at a famous hotel and he believed that one should never be seen sitting down. So I stood to attention at the front doors for up to eight hours a day, broken by rare trips to the wards with patients.
Standing still is not hard for a short time. After about half an hour the soles of your feet feel a little uncomfortable. You shift position a little, raise one foot then the other...then walk to the other side of the door. If you are caught too far from your post, you are chastised. If you do it again you are told that your pay will be docked. So you stand on the spot.
The soles of your feet start to throb after an hour or two, and yet the day has barely begun. By lunchtime you can think of nothing else. A trip to the ward is blissful. You dawdle back as slowly as possible, but before long your feet feel like enormous insistent throbbing lumps. You can think of nothing else. It is hard to believe that such a simple duty could be made into endless days of torture, so when I was offered an alternative I accepted without hesitation.
The mortician, technically an orderly, was taking leave. A temporary replacement from among the orderlies was required. As a group, it was thought by the other orderlies that, since I was a medical student, it might be educational for me to do the work. In principle, and in view of my newfound relationship with my feet, I tended to agree. And so I was taken to the mortuary and instructed in my new employment.
I was shown how to remove the internal organs from the larynx to the bladder and rectum using a scalpel to make an incision from each shoulder to the base of the sternum then vertically down to the pubic bone. The organs were placed in a large dish for the pathologist to examine later. Then the thoracic and abdominal cavities were filled with scrunched up pages of a large broadsheet newspaper and the incision sutured with a running stitch of string so that funeral arrangements would not be delayed. Leftover organs were later poured into a garbage disposal sink. When I first saw the procedure I tried to maintain my external composure. Internally, I had the sensation that my brain was being sucked out of my skull leaving me without the capacity to frame a response - my own reciprocal "out of body" experience. I was clearly emotionally unsuited to the task but there was no option to turn back now.
A new body was brought into the mortuary and I was left alone to do the job. People say " I have never felt so alone." Well, this was one of those occasions. There was no time pressure so I waited.
Waited for inspiration, for courage. Hoped for escape. The waiting made it more difficult to face the procedure. I can still remember the smell of dead body and disinfectant and the feeling of unreality. Then, like an automaton, I simply pulled back the sheet and did the squelching, cartilage-crunching ,nauseating operation. And then the next, and the next. Eventually I became hardened to the experience but now I was socially isolated. Previously a few people would sit with me at lunchtime. Now no one came to my table. No one would make eye contact. I had become a pariah.
The experience was overlaid with the fact that my father was in remission from his metastatic bladder cancer which hung over our close tiny family like a shroud. In short, I probably didn't cope as well as I thought at the time. It might also at least partly explain my erratic behaviour in the first two years of my medical course.

To handle a corpse is not quite the same as seeing a person die, however. This didn't happen until my intern year, on a rural placement.
The hospital was more than three hours from my family home, which was a rented apartment that I shared with my parents and my girlfriend. My father was coming closer to the end, only a few months away as it transpired, although he was still managing the palliative care patients at the cancer hospital. He was functioning normally on two hundred and forty milligrams of morphine every four hours but the stress level of the household was rising. My girlfriend, also a medical student, left me at the beginning of the new term, although we eventually limped on with our relationship for another two years.
I was emotionally and geographically isolated, and generally sad, but still enthusiastic for the work.
The hospital was run by the radiologist and the GP's.There was a medical resident - me - and a surgical resident who looked after the inpatients and treated the casualty presentations.

 The first day that I arrived on the ward it seemed quiet and empty of staff. As I explored the ward I became aware of a rhythmic sound from one of the rooms.As I came closer I could hear counting from one to five then the sound of blowing air repeated over and over. When I reached the source of these quiet but persistent noises I found two middle aged men leaning over a man of similar age lying on a bed. One was was performing cardiac compressions while the other was squeezing a bag of air into the lungs after every fifth compression of the sternum. Seated in a bedside chair, a middle aged woman was calmly knitting. I asked if I could help.One of the men, both local doctors I later learned , suggested I come back when they were finished.
The patient was their colleague who had suffered a cardiac arrest. His wife was the calm knitting lady.Apparently it had happened more than once before and, as on this occasion, he survived. But it was a somewhat surreal introduction to the hospital.

Not long after this I was called to see a man in casualty with atypical chest pain. His ECG was unremarkable so a chest X-ray was arranged. Since I wasn't busy I decided to watch his X-ray. There was some delay, so I stood beside his trolley chatting with him. He seemed a nice man; I was enjoying the conversation. Suddenly, he began to lift his head and shoulders up while making a loud frightening roaring sound. I had done six years of medical training and two thirds of an intern year but I had no idea what was happening. His face was engorged with blood. The veins in his neck were bulging fit to burst. I felt that I should be doing something. I asked him what was wrong but got no response. I tried to take his pulse but it wasn't possible to feel anything with his rigid trembling roaring condition.
I called for help but no response. I didn't want to leave him like this. I ran a few steps down the corridor and called again then returned at once, as he started to quietly sink back down. Now I could check his pulse - nothing at the wrist, nothing in the neck. I finally realised that this was a cardiac arrest and climbed up onto the trolley to do the CPR. I seem to recall it went on for a long time without any response, even after help arrived with the appropriate equipment. Eventually the resuscitation was abandoned. I was sweating, disappointed and disorientated.
I had been to cardiac arrests before and they were exciting. I always wished that I could be the one at the centre of the procedure. It looked important and, to be honest, fun. But this had not been fun. A nice man had died. Despite my extensive training I had been powerless to help him. On reflection I think perhaps he may have had a massive pulmonary embolism, in which case there was never a chance of a successful resuscitation. I don't think I ever found out the diagnosis. He may not have had an autopsy at all, as it is often simply recorded as cardiac arrest "due to coronary artery disease."  In similar circumstances I know I have made such guesses as a resident doctor in order to spare the family an unwanted intervention by the coroner. It has been written that pulmonary embolism is a more common cause of death than the official records indicate. Despite this, he is the image that comes to my mind when I think of a cardiac arrest. I have been taking low dose aspirin since I turned forty for that reason, even though my risk profile suggests it is more likely to give me a stroke than to save my life.

While writing this I have done two consecutive clinics without a break including an emergency Caesarean section and another run to the labour ward for a two and a half litre primary post-partum haemorrhage. It is odd but I no longer feel tired.