Deep End
DEEP END
My first week as a BST 2 started with a bang. It was entirely coincidental, but somehow, I was assigned so many challenging cases that, within days, I felt as though I had been thrown straight into the deep end.
Over the course of that week, I cared for two relatively young men in their forties who presented with clear signs of acute stroke. I moved as quickly as I could, doing everything in my power to get them assessed, scanned and treated as rapidly as humanly possible. Fortunately, both went on to recover well, returning to their previous level of function within a few weeks.
The neuroradiologist was so impressed by how quickly I had responded that he offered me a job on the spot. Little did he know that I was absolutely in love with my current job – or that one cannot simply switch specialties on a whim. But yeah, I was so damn proud of myself!
The Harbinger of Death
But then… then came a string of cases that left me feeling utterly helpless. Patients for whom I had done my very best, yet despite my best efforts, none of them fared too well.Â
Three different patients presented with vague abdominal symptoms. I eventually arranged scans for each of them, only to find that all three had findings strongly suggestive of metastatic cancer – disease that had already spread beyond its original site and was unlikely to be curable. On three separate occasions in a single week, I had to explain that the scans had revealed something devastating. It felt as though I was handing three people a death sentence. I had done my job properly, yet there was still nothing I could do to make the news less terrible. Thank god for Meredith’s speech that week – something I thought of during the hardest of times…
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Then came that one case. His name, out of sheer chance or a cruel twist of fate, was Marius. He was a man in his early forties who had undergone a bilateral lung transplant several years earlier. Since then, he had experienced complication after complication, including progressive graft dysfunction.Â
He came in with haemoptysis – coughing up fresh blood. Not a good sign. His family were distraught. So was one of my immediate seniors – a relative of his and someone I had worked with for a year and grown close to. She happened to be on leave, so the initial responsibility for assessing him fell to me.
By the time I saw Marius, the bleeding had stopped and his observations were stable. It felt as though I had done very little for him, although I assessed him, took bloods and ordered a chest X-ray, which showed changes concerning for pneumonia. I discussed the case with the medical registrar and asked whether they wanted any further investigations. Given that he was stable and the chest X-ray already suggested infection, they advised holding off on further imaging for the time being and starting antibiotics, with reassessment if his condition changed. It seemed like a sensible plan – one I agreed with. And so, that was what we did.
Over the next few days, Marius deteriorated. The medical team and my senior later reassured me that his underlying disease was so advanced that there was probably little we could have done to alter the outcome. Even so, I kept wondering whether I had missed something. Should I have pushed for a CT scan? Should I have argued for stronger antibiotics? Should I have done more?
Probably not. Perhaps none of it would have changed the course of his illness. But I could not know that with absolute certainty, and some part of me still felt responsible – even though I had assessed him, sought senior advice and followed the plan we had agreed upon.
The Limits of Medicine
Each time, I left the hospital wondering why on earth we bother doing any of this and how futile it can all seem. Life just sucks sometimes, doesn’t it?
That is the nature of the job. Life and death. We fight and we fight to keep death at bay. Sometimes, we win the battle. Eventually, though, medicine always loses the war.
That was my first lesson as a BST 2 – that even when we assess carefully, escalate appropriately and make a defensible plan, there is only so much we can do. We are not always able to change the outcome. Sometimes, all we can do is make the best decision available to us at the time, then carry the weight of wondering whether it was enough. Humbling. And sobering.