An unforgettable medical memoir
A very personal account of the career and life of a leukaemia physician
My father's death
A memory from an 8 year old
I remember this vividly. The six of us were having our usual noisy dinner at the kitchen table. My mother was there, but not eating. The knock at the front door was loud and firm and could not be ignored. My mother looked startled, almost frightened, and immediately left to open the door. There was a difficult, deep silence, with us looking at each other. What was happening?
After a while, I went out into the hall. I saw a flash of blue and white of a policeman’s harsh uniform leaving, and, for the first time ever, my mother wiping away tears. She came back to the kitchen with her hair tied back severely and asked the oldest four to come into the adjoining study. She said, unceremoniously, “Dad’s dead.” My three older siblings, John, Andrew and Jenny, stiffened, then burst into tears. At the age of eight, I didn’t feel anything. “Was he murdered?” I asked. “No,” she said. “He died in a car crash.”
We didn’t finish our dinner and went to bed early. The following morning, there was a line of bags by the garage door. My mother had spent the night packing up my father’s clothes to donate to charity. I don’t think she slept that night. The next morning, I remember seeing her in the playroom, talking to my two youngest brothers about the accident. Unusually, for my non-tactile mother, my brother Bruce, who was four, was sitting on her knee.
It all felt so bleak, so hopeless: we knew our lives had changed forever. My mother was left on her own with six children to look after. She did her best, but never got over my father’s death, and at times was not available to us. We would have to be strong.
A Covid Fantasy: being infected with Covid-19
As much of my writing has been during the pandemic, I thought I should write something about the virus itself. I have a major interest in viral infection in transplant patients, and I am the infection lead for my cancer centre. From March in 2020 until now, I have provided expert advice so that we minimise the Covid risk to staff and patients. It has been a lot of work. At the time of writing late in 2020, we know that steroids improve the outcome of Covid pneumonia and there is the promise of a vaccine (although nobody has had it yet).
During the pandemic, many frontline hospital doctors were scared of getting infected with the virus, then developing progressive fever and shortness of breath due to viral pneumonia. Here is a possible sequence of events. After developing symptoms of the virus, possibly acquired from a patient, I would be at home, quite unwell, spending a lot of time in bed. I would become anxious, constantly checking your temperature, hoping it would subside and asking people to listen to your chest with a stethoscope for evidence of pneumonia. Some doctors with Covid bought oxygen saturation meters from Amazon to monitor their progress: these would show a progressive lowering of oxygen levels to the low 90s (95-100% is normal). In the early phases of the pandemic, a radiologist in China posted serial ultrasounds of his lungs on Twitter. It was tense reading his tweets: we were all scared his pneumonia would get worse and he would die (in the event, his lungs got worse for several days, but then he improved). In periods when patients were not allowed visitors, I fantasised about being taken to the hospital by my family (or, if I was very ill by an ambulance), and saying goodbye at the entrance to A & E, knowing that this might be the last time I saw them.
I would wait around for hours in a very crowded A & E (among other patients who might be even sicker), but eventually I would be swabbed, X-rayed and a history would be taken. After transfer to one of the Covid wards, I would be seen by a junior doctor who would be worried about looking after me because I am a medical professor (there are both advantages and disadvantages of being ill when you are a doctor yourself). I would have an oxygen mask on, to ease the breathing problems but which would be claustrophobic. All the staff in the Covid ward would be wearing special, tightly-fitting masks, visors, goggles, gloves and gowns: I wouldn’t be able to see their faces or know what they were thinking, while also having a clear view of other struggling patients across the respiratory ward. The bleeping oxygen saturation monitor by the bedside would record a decreasing percentage of oxygen and the flow rate of the oxygen would be turned up until it reached 15 litres per minute (the maximum). I would have been given the steroid dexamethasone and probably the antiviral remdesevir, and I would have been offered entry onto the national Covid Recovery trial, where I might receive additional therapies. I would desperately want to be randomised to the experimental arm of the trial in the hope of receiving treatments such as antibodies or plasma; when you are extremely ill, you are not interested in helping other people by contributing to knowledge of the virus and its treatment on the control arm.
All the time, the medics would monitor my respiratory rate, which would slowly increase. Normal is 12-16 breaths times per minute. At the point of deterioration, they would strap on a tight-fitting high-pressure mask (CPAP: continuous positive airways pressure) and the intensive care consultant would assess me. This would be awkward because I would know them, but by this time I would be beyond caring. The consultant would assess me medically, sizing me up as a candidate for intubation, and tell me that they would need to do the intubation pre-emptively, before I ran out of breath. Would I have enough respiratory reserve when they removed the tube? I even fantasised about telling the consultant that, although I am 63 and a little overweight, I can ride a bike faster than almost any doctor in the ITU.
All the while, my family would be worrying about me, and because the hospital would be so busy, they would have trouble getting through to the ward. I would phone home to tell my wife and children what was happening, that I was moving towards intubation, that I might not wake up again, and that it could be two weeks before the outcome was known. You would do this on the Family WhatsApp group chat, realising that they could see your distress and your shortness of breath. The palliative care consultant would come to see me, to ascertain my wishes. This is called ‘parallel planning’, hoping for the best but preparing for the worst. She would remind me that I don’t have to choose to be intubated, but that if I do survive my quality of life might be very impaired. She would explain the reasons why they might decide to stop active treatment. Of course, I know the reasons: God knows I have been on the other side often enough, making decisions about patients not doing well in ITU and ‘turning them off’. I would ask that my wife be kept informed because I know she will make good decisions while I am sedated; she wouldn’t want to keep going if things were hopeless. Time would be compressed. I would type individual letters to all my immediate family, a brief goodbye email on my laptop, telling them that I love them, that I don’t want my death to ruin the rest of their lives, that they should continue to live their lives…and that I might survive! I can barely imagine the effect of receiving this email.
None of this happened, but it could have. Working as I have done over the last year, I am sure I have had the virus on my hands and probably in my nose, my mouth and my eyes. I admit I was scared. I even calculated my chance of dying if I got the virus, adjusting for my age and gender: about 1.5 to 2% of dying a death where you run out of breath. I overcompensated by reading everything about the virus and working hard to get our cancer centre to do sensible things to protect staff and patients from the virus. I started wearing a mask long before anybody in the hospital (in March 2020, before the first lockdown), walking on the road as people approached on the footpath. At work and at home, I made so many efforts to avoid getting infected.
The background to this is the inept way the UK has dealt with the viral epidemic. The UK is good at medicine, pretty good at science and very strong at randomised clinical trials. So what has been good? The randomised controlled trials led from the UK have identified therapies that have improved survival in Covid patients. This is world-leading work. The purchase of vaccines has been aggressive and ahead of most countries, but now excess vaccine doses need to be donated to poorer countries. The MHRA (regulatory authority) rapidly approved the Pfizer vaccine, way ahead of the FDA and EMA, which meant the vaccine roll out was early. In my opinion, everything else has been very poor. Being too late with every lockdown, overriding or ignoring the scientists, inadequate testing, poor tracing of contacts, delaying the second dose of the Pfizer vaccine without any data, being late with acquiring personal protective equipment (PPE)…I could go on, but there’s little point. I have spent most of my professional life working here and I expected much better.
Update: I have had two doses of vaccine now, and that makes it less likely that I will get very ill (but not impossible, given the big dose of virus that some doctors are exposed to).