We're delighted to present an extract from The Ministry of Bodies (published by Head Of Zeus), the new book from acclaimed 'poet-physician' Seamus O'Mahony, the award-winning author of The Way We Die Now and Can Medicine Be Cured?
Life and death in a modern hospital: Seamus O'Mahony charts the realities of work in the 'ministry of bodies', that huge complex where people come to be cured and to die. From unexpected deaths to moral quandaries and bureaucratic disasters, O'Mahony documents life in the halls and wards that all of us will visit at some point in our lives with his characteristic wit and dry and unsentimental intelligence.
'Only God can judge me'
For fourteen years I was one of just two consultants in the gastroenterology department; we eventually – slightly too late for me – grew to four. We shared inpatient duties and on-call, spending half our time ‘on’ for the wards. When ‘off’ the wards, we did our ‘elective’ outpatient clinics and endoscopy lists. When ‘on’ the wards, we did everything: on-call, ward rounds, outpatient clinics, endoscopy. Our department sometimes had over sixty inpatients, looked after by two of the four consultants, who rotated this duty. By the time I reached my late fifties, this workload had become intolerable.
The inpatients were a mixture of general medical patients and people with what were deemed to be specifically gastroenterology (‘gastro’) problems.* The general medical patients came under our care through what was called acute ‘take’: when on ‘take’, or call, for general medicine, we took those patients whose problem – usually problems – made them unsuitable for admission under specialist departments such as cardiology and neurology, who took only those patients whose problem was deemed to be specifically within their remit. Most ‘medical ’ (as opposed to ‘surgical ’) patients were frail elderly people who were allocated to the physician or department on ‘take’. The byzantine rules governing medical ‘take’ had been laid down forty years before, when the ministry opened, and were seen to be as unalterable as the tablets of stone, immune to the dramatic changes in medicine and demography over those four decades.
Roughly half the inpatients under the care of our department were general medical, and half were ‘gastro’. Most of the ‘gastro’ patients had alcoholic liver disease. When I started in the 1980s, liver cirrhosis was relatively uncommon in Ireland. Despite the lazy racial stereotype, the Irish in those days were, per capita, modest consumers of alcohol compared to other Europeans, such as the French and the Spanish. Many people of my parents’ generation were teetotal, often for religious reasons, being members of the Catholic Pioneer Total Abstinence Association. By the 1990s and 2000s, Ireland’s alcohol consumption had risen sharply, leading to an epidemic of chronic liver disease. This epidemic also took hold in Britain. I spent much of my consultant career at the ministry caring for the victims of this epidemic.
When a colleague handed over ward duties to me, the short summary of a patient given the day before in the ‘handover’ didn’t always conform to what I saw on the ward round. ‘Oh, don’t worry about Mr Murphy,’ they would say, ‘he’ll probably be gone by tomorrow’, or ‘he’s waiting placement in a nursing home’, or ‘there’s nothing more to be done; he’s dying’. Then I did the ward round, and found Mr Murphy’s family gathered around the bed, wanting to know why he was still waiting for a CT scan, and why hadn’t he been referred to a geriatrician, and could somebody please tell us what’s happening with Dad?
The ward round was once the central ritual of life in the ministry, where all important decisions on patient care were made. The round had designated days and starting times, and the team of doctors (consultant and juniors) were joined by the most senior nurse. The ward round was just that: it started and finished on one ward. When the ministry was new, there were even teaching rounds. Then, all the doctors wore white coats and the nurses wore white uniforms. There was an office in the basement laundry where clean starched white coats could be picked up on Monday mornings. The many generous pockets in these coats could easily accommodate a stethoscope, bleep, a copy of the British National Formulary (for guidance on drugs), several pens, an ophthalmoscope, a packet of cigarettes and a lighter. Now, white coats have been banned on the grounds that they pose an infection risk; two refusenik consultants continued to wear them. The junior doctors wear either theatre ‘scrubs’ or ‘smart casual ’ attire, and never a tie. The senior nurses wear a striped blue and white top with blue pants, while the junior nurses are attired in white.The ‘allied health professionals’ – physiotherapists, pharmacists and speech and language therapists – are easily identifiable by the colour of their tops, being, respectively, white, green and red.
Four decades on, the ward round continued, but bore little resemblance to the choreographed event of my youth. Over several hours and multiple locations, the ‘team’ often got broken up. One of them might stay behind on a ward to write up medications or order X-rays; nurses often phoned the juniors after we had left the ward to find out what we had decided. Meanwhile, the wards we had not yet visited would call, wondering when we would arrive; smartphones provided endless opportunities for interruption. I generally began the round with a team of three or four (rising in seniority from intern to senior house officer [SHO] to registrar), but this usually dwindled to one or two as they were called away to attend to something else more pressing. Outside my home ward, the nurses were less attentive and the charts more difficult to find. Rival and competing conversations often took place at a patient’s bedside. While I was trying to take a history from an old, deaf, mildly demented patient, a physiotherapist might be next to me, discussing another patient with my senior house officer. Record-keeping was ad hoc and haphazard, with the juniors writing in the notes their rough interpretation of my assessments and plans. These synopses were sometimes wildly incorrect.
But the main problem with rounds was decision-making. A round could not last longer than three hours; the team needed enough time to act on the agreed plan. Assuming thirty patients over three hours (I had very often seen more than fifty), that gave an average of six minutes per patient. For many, no major decision was required: they were working their way through treatment and investigations already planned and agreed; other patients were awaiting ‘placement’ in nursing homes. Six minutes was enough. For many others, however, six minutes was spectacularly inadequate: they might be new to me; they might not be responding to treatment; they – or their relatives – might require personal time with me; one or two might be acutely sick and in need of urgent attention.
Important decisions, therefore, had to be made quickly, very often without all the necessary information. On an average round, there were perhaps ten to fifteen such decisions to be made. More than once, I had committed errors under this intense pressure. After a major blunder, I knew I had to find a way of managing this. I developed an acute awareness of uncertainty and my own limitations. If I felt unsure, I told the patient. I explained that I couldn’t make that decision right now, that I needed to think about their problem, or take advice. I felt no shame in saying this.
When I took over ward duties this morning, I had only twelve patients to see, but it took over two hours: I didn’t know them, and they were scattered all over the hospital. Most acutely admitted patients came in through the emergency department, where they were accommodated on trolleys for hours or days, and then sent to wherever a bed could be found ‘up the house’. I struggled with some and hoped that the registrar and senior house officer were doing a vague approximation of the right thing.
*
Sharon, a patient whom I had encountered on previous periods of ward duty, was more complex than most. She had many problems; a solution to these would be unlikely, given her hatred of doctors and her dependence on alcohol. She wore an old threadbare Arsenal replica shirt from the early-1990s’ George Graham era; her wasted arms were heavily tattooed. (I could read one, which proclaimed: ‘Only God can judge me’.) ‘You’re just going to fuck me out the door without sorting me out,’ she spat. You’re probably right, I thought. She discharged herself later that day ‘against medical advice’.
*
An Englishman with alcoholic cirrhosis had been transferred the day before from the small county hospital in west Cork; he had a huge mane of grey hair and a full, Old Testament prophet beard. (I have often been struck by the sheer hairiness of men with liver cirrhosis: you hardly ever see a bald one.) West Cork was full of retired English people, a migration that had always puzzled me. I suspect they arrived as tourists on a sunny summer’s day, became intoxicated with the scenery and the charm of the locals, and as soon as they were back home in Doncaster or Croydon, they were looking at Irish properties online. Before they knew it, they were in Kealkill, staring out at the rain on a wet November Wednesday, wondering what had possessed them. It’s no wonder they took to drink.
*
Alan was on a trolley in the emergency department. He was now thirty-five; I had known him since he was a teenager. His case notes were in five telephone-directory-sized volumes; he had been attending the ministry since both he and the institution were in their infancy. He had spent at least half his life here and over the years had developed a weary cynicism in his dealings with doctors. Fixing me with his watery eyes, Alan asked: ‘What’s causing this pain?’ He might as well have asked me to explain quantum mechanics.
To the surgical ward, to see another cirrhotic woman, Colette. Only thirty, she was so jaundiced her skin colour had progressed from yellow to green. With a sublime disregard for her plight, she announced that she would go home. I told her that if she did so she would die, but I wouldn’t stop her from leaving.
My lack of opposition – indeed indifference – to this threat was paradoxically effective, for she made no further mention of it. The nurses asked me whether they should call security if she tried to bolt; I told them she had the capacity to make her own decisions, and that no obstacles should be placed in her path. The senior nurse didn’t disguise her disapproval of this: ‘What if she dies?’ She would die anyway, I thought, here or at home, now or later. But that wasn’t what worried her; she had visions of a newspaper headline: ‘Woman fatally injured by lorry minutes after absconding from hospital ’.
Delusions of competence
Every Monday morning, Terence, head of the health and wellbeing service for the southern region, sent an email to ‘all users’ with his ‘weekly wellbeing messages’. There were always three: one on ‘spirituality’, a second on exercise and a third on diet. Did Terence deliberately choose Monday morning to send these messages – thinking it the time when we coalface health workers would be in most need of his encouragement?
Here are this week’s suggestions:
· Accept your flaws, they make you you
· Dance like no one is watching
· Eat a pear a day
Terence started sending these messages early in 2019. His many ‘spiritual ’ exhortations included: be thankful for what you have; lending an ear is lending a hand; rest to recharge your batteries; do something kind for someone today; ask your colleagues how you can help them; tell someone you are proud of them; appreciate the world; list five things you are happy about; three hugs a day; forgive and forget; stop comparing yourself to others; give somebody a compliment; give yourself credit for your achievements; do more of what you love; be open to new ideas; surround yourself with positive people; appreciate the beauty of nature; learn from your mistakes; spend time with those who you love; recognise your strengths; be proud of who you are; be kind to yourself; keep a positive attitude; don’t take tomorrow to bed with you; laugh more; make a new friend; be your own best friend; do not fear change; live in the moment.
I almost looked forward to these banalities; they eased me into the week. I had a vision of Terence at his desk in the Skibbereen office of Cork-Kerry Community Healthcare, his desk groaning with books by Deepak Chopra, Paulo Coelho and the Dalai Lama, wondering what messages to send every week. My colleague David, however, viewed Terence’s dietary tips (‘practise mindful eating’) as dangerous nonsense. When Terence advised ‘all users’ to ‘be sure to drink 2 litres of water per day’, David was infuriated enough to email me:
‘Be sure to drink 2 litres of water per day.’ Unless, of course, you (1) Don’t trust your own highly sensitive thirst regulation; (2) Have chronic heart failure; (3) Have psychogenic polydipsia; (4) Think that it is strongly evidence-based; (5) Drink too much of it; (6) Think that you will lose weight by it; and (7) Don’t mind the odd bug.
‘These messages are such hogwash,’ he wrote, ‘and not as harmless as they seem.’ I replied to David that while I agreed with him, he should really write to Terence with these concerns.
A woman was ‘handed back’ to me over the weekend: she had been admitted under another physician, but because she had been under our service (with a completely unrelated problem) within the previous six months, we were obliged – by the ancient rules governing medical ‘take’ – to accept her back under our care. She was suffering such severe alcohol withdrawal that she required not only large doses of sedatives but also the continuous presence of a ‘special ’ – in this instance, a burly African care assistant – to prevent her from hurting herself or any of the staff, and to stop her from defenestrating. A psychiatrist suggested a stint in a rehabilitation unit. She told him that she didn’t have any confidence in this unit.
‘Why is that?’ he asked.
‘Because I worked there as a counsellor.’ Did she lack confidence in this unit because she knew from her experience there that it wasn’t very good, or because they were foolish enough to hire someone as troubled as her?
When I saw her the next day, she seemed greatly improved. She talked warmly of her home village and her GP. This conversation went on for some time before my registrar whispered to me: ‘She’s not our patient.’ This new woman now occupied the same single room where my alcoholic addiction counsellor had been ‘specialled’; she had been transferred overnight to another ward. I hadn’t caught a very good view of her the day before, curled up in a ball, hidden beneath the bedclothes while she weathered the horrors of delirium tremens.
Alan, the full-time patient who was on a trolley in the emergency department when I last saw him, was now languishing on a surgical ward. An on-call junior doctor had, for some unfathomable reason – probably at the prompting of a dietician – requested blood phosphate levels on Alan. His phosphate levels were low, which led to several intravenous phosphate infusions, with little effect on his pain or his mood. Someone else had ordered an MRI scan of his liver, but this could not be done because Alan had metal somewhere in his ravaged body. Now he wanted to know why he was so deficient in phosphate and why couldn’t he have the MRI? After a long conversation with him, I took the registrar and senior house officer aside.
‘Alan is a super-tanker,’ I explained. ‘Super-tankers can have only one captain, one doctor who makes any significant decisions. Alan’s captain is not "on" for the wards right now, so we should do as little as possible. Preferably nothing.’
I greeted the hospitaleras† on the main corridor: that small group of older women who, despite having no official appointment or institutional recognition, spent most of their days in the ministry. They ate in the canteen and attended daily mass in the chapel. I nodded to each in turn; I knew them all.
When the ministry opened, you could smoke almost anywhere: in the canteen, in the ward day rooms, in the medical students’ locker room, in the junior doctors’ lounge, in the surgeons’ coffee room, in theatre. ‘We must stop for a smoke,’ one registrar who worked at the ministry in the 1980s would order her willing consultant, mid-ward round. This saturnine, elegant man would then join her for a cigarette in the ward sister’s office. Even the shop on the main corridor sold cigarettes. Now the smokers were banished, and you could no more buy tobacco in the ministry than you could a bottle of whiskey. Staff who were smokers either went out to the main road, to a corner adjoining a suburban street, or to their cars, which, strictly speaking, was not allowed, since the entire campus was now non-smoking. There were still a few smoking doctors; one didn’t bother to skulk: he puffed insouciantly in the ambulance bay by the emergency department.
Because our department (offices, secretaries and outpatient clinic) was housed in a building near the periphery of the campus, I walked through the main entrance several times every day on my way to the wards or the endoscopy unit. The drug reps, with their tight suits and shiny brown shoes, congregated just inside the door, while outside were the smokers. They gathered in a comradely huddle, often sheltering from wind and rain, in their pyjamas and dressing gowns. Some carried urinary catheter bags; others grasped their drip stands, like the figures from Géricault’s Raft of the Medusa clinging to the mast of the raft.* Immediately above the ministry entrance, a public address system played an announcement on a continuous loop. The voice (with an English accent – still the sound of authority in Ireland) admonished them for exposing the patients in the breast and cardiac units to their second-hand smoke.
Middle-class families walked or cycled through the ministry grounds on their way to the local schools. Some of the parents were ‘presentational ’ – their conversations with their children meant for a wider audience: ‘Cian, Sadhbh: that’s a blackbird; the other one is a jackdaw!’ A few cycled behind their children, like the domestiques in the Tour de France.
Felix
The building that housed the gastroenterology outpatient clinic was near the back entrance of the ministry. Although this outpatient clinic had been specially established for that group of women who had been infected with the hepatitis C virus after receiving the anti-D vaccine,* the ministry agreed that all the other liver and gastroenterology outpatient clinics could also be held there. The main hospital outpatients was shared by many different departments, but this clinic was ours: we had our own nurses and receptionists; the waiting area and four consultation rooms were bright and spacious; the two secretaries and four consultants had their offices there also.
Felix, the first patient that day at the clinic, had chronic abdominal pain. His name only drew ironic attention to his gloomy disposition; Felix lived in a hell of his designing. I had investigated this pain extensively, finding no cause. ‘Yer doin’ nathin’ for me,’ he said in his drawling monotone. I reassured him that all the tests were clear, and that this was good. Felix was not consoled: ‘Yer hidin’ somethin’ from me. I know ye are. There’s somethin’ awful wrong with me.’
An urgent email from a middle-ranking manager, the ‘lead for unscheduled care’:
The hospital is in the highest level of escalation this morning with 27 patients in the ED [emergency department], 12 patients in the AMAU [acute medical assessment unit] and 7 patients across the main wards who have not been allocated a bed. This is the case due to low number of discharges over the weekend. Including the 21 elective admissions this morning who also need beds, there is a requirement for 66 beds as we start the day. In order to de-escalate the hospital the Flow Team need to have early visibility of potential discharges. There were 45 potential discharges highlighted at 9 am and this does not meet the current demand.
The management narrative – a cynically clever one – was that the ‘trolley’ crisis* was due to ‘low number of discharges over the weekend’, not an inadequate number of beds. If only the consultants could be bothered to come in at weekends and discharge patients, we would not be faced with this problem on Monday: the doctors had failed to maximise patient flow.
Tim, the radiologist who chaired our weekly X-ray conference, was away; nobody could deputise for him, because the radiology department was ‘swamped’. This meeting was important. Tim reviewed X-rays and scans of patients we had concerns about; not infrequently, he overturned the diagnosis of his radiology colleagues. Many – if not most – of the weekly conferences like this (particularly those held over lunchtime) were ‘sponsored’ by the pharmaceutical industry, who supplied food and drinks. I had long since declined this largesse; none of my colleagues shared my unease. A drug rep stood forlorn by the sandwiches and tins of Diet Cola he had provided for this meeting, which would now not proceed.
One of my colleagues instructed the juniors to eat the sponsored lunch; it was, he said, ‘the least we could do’.
On call today, general medical ‘take’. I took a call from a locum consultant at a small private hospital sixty miles away. He spoke for some time about an elderly male patient; all I could ascertain from this monologue was that he wanted to transfer him as quickly as possible.
‘What do you think is wrong with him?’ I asked.
‘I don’t know, but he needs multidisciplinary care.’ I could sense his desperation. ‘Multidisciplinary care’ was clearly something not provided by this private hospital. I explained to this doctor that I would do my best to find a bed for his patient at the ministry, but given the fact that over twenty patients were being accommodated on trolleys in the emergency department, it was unlikely that I would be able to get the patient in that evening. I asked him to email me the patient’s details; I never heard from him again.
*
I wasn’t disturbed overnight, a great relief, since being woken by a call from the ministry had become increasingly onerous. I found it nearly impossible to make rational decisions after being shocked out of a deep slumber, and often struggled to get back to sleep. As usual after a night on call, I got up at 5.30, breakfasted in my office at 6.30, and started at 7.00 in the emergency department, where most of my patients would be accommodated in cubicles or on trolleys. I struggled, as always, to find somewhere wide enough and flat enough to write in the notes, and a clean, empty sink in which to wash my hands between patients.
An elderly woman lying on a trolley with a fractured pelvis and collarbone (sustained after a fall), cellulitis and septicaemia looked ghastly. Her husband and daughter hovered anxiously, while a nurse told me, in a loud whisper, ‘Her blood pressure is dropping!’ Having delivered this message, she walked off.
A man with heart failure. He was only sixty-two, but this was his third admission in six months. He attended several services (respiratory, cardiology, diabetes). Who would have the difficult conversation with him? Who will tell him that he won’t survive another year?
The Ministry of Bodies by Seamus O'Mahony (published by Head Of Zeus) is out now.
About The Author: Seamus O'Mahony is a doctor and author. His first book The Way We Die Now won the British Medical Association’s Council Chair’s Choice Book Award in 2017. His second book Can Medicine Be Cured? was published in 2019. He is visiting professor at the Centre for the Humanities and Health at King’s College London. He is a regular contributor to the Dublin Review of Books and the Medical Independent, and has written also for The Irish Times, the Observer and the Saturday Evening Post.
