Book Review: Breaking and Mending

This review was written for and first published by Bookmunch.

“medicine is all about people, and people are made out of stories”

Why would anyone wish to become a doctor? It is a question most potential students applying to medical school will be asked. Perhaps they wish to save lives, to make a difference. Perhaps they come from a family of medics and it has always been expected of them. 

It costs around a quarter of a million pounds to train a doctor in the UK, a significant proportion of which must now be borne by the student, often in the form of debt. The course is one of the most demanding offered by universities. And yet for every place available, four people who expect to achieve the necessary exam results will apply. It is and remains a competitive career choice.

Joanna Cannon entered medical school in her thirties. She was accepted by the admissions panel as a wild card. Her motivation throughout the long years of training was to get into psychiatry. Breaking and Mending is the story of her experiences on hospital wards as a student and then Junior Doctor. It is a sobering indictment of how medical professionals – the people entrusted with individuals’ myriad and complex health issues – are treated by the NHS and certain of its senior employees.

“Stories bind us together, stories unite us, and we tell our stories in the hope that someone out there will listen, and we will be understood.”

Cannon’s story is told in snapshots that she describes as her Kodak moments. Each chapter details an encounter with a patient or colleague, the memory of which she carries with her. The burden of her emotional responses over time became a weight that she struggled to bear. The long and busy shifts a doctor is required to work took their toll and she found it ever more difficult to be the type of doctor she had worked so hard to become.

Written with grace and candour the descriptions and reflections are a balance between compassion, valuable learning and simmering anger. There is much for the reader to contemplate and absorb. Doctors work to ease suffering and delay death under exhausting conditions. Given the lack of care they themselves receive it is little wonder that too many of them face burn out.

Yet this is not a polemic. It is a very personal story that cuts to the heart of issues faced by a vital profession dealing daily with human suffering. Doctors must somehow find a way to inure themselves while showing others care and understanding. Their role goes beyond prescribing and administering appropriate clinical treatment. Good doctors learn to listen to the stories they are told by patients and to find the right words in response. They also benefit when colleagues notice and find time to listen to them.   

Any Cop?: Cannon is a skilled storyteller and this is a poignant and thought-provoking medical memoir. It highlights the importance of talking about topics that make many uncomfortable such as death and mental illness. It underscores the stigma doctors face if they admit they are struggling to cope with the conditions under which they are required to work.

 

Jackie Law 

Book Review: War Doctor

In a growing field of medical memoirs War Doctor stands out for its purpose – to increase awareness of the reality of modern warfare on the individuals and communities directly affected. The author has volunteered his services as a trauma surgeon in active war zones including: Afghanistan, Sierra Leone, Liberia, Chad, the Ivory Coast, the Democratic Republic of the Congo, Sudan, Iraq, Pakistan, Libya, Gaza and Syria. He pulls no punches in his descriptions of the horrific injuries and personal dangers encountered in each of these places. By describing the treatments offered as he attempts to patch up bodies torn apart by weapons designed to inflict maximum damage, his story avoids polemic. Rather it is a humane account of the many good people risking their lives to help those caught up in evil deeds carried out by those seeking to gain or hold on to power in a region.

David Nott spent his early years in rural Wales before moving with his parents to England. He studied medicine at the Universities of St Andrews and Manchester, staying in the north of England for his Junior Doctor years. He realised during this time that he wished to work in war zones where his surgery could make a significant difference. He set out to gain relevant experience.

“I’d need a fantastic breadth of knowledge in general surgery, which I was on the way to achieving. And I realized it would also be good to know a lot about vascular surgery, too: if I was to spend time in dangerous places, I’d be seeing and dealing with a lot of injuries from bullets or bombs, and knowing how to clamp off blood vessels would be essential.”

Nott’s first consultancy post was at Charing Cross Hospital in London. Surgeon friends there told him about Médecins Sans Frontières, an organisation offering short placements abroad for medical personnel. With agreement from his employer, Nott was able to take unpaid leave from the NHS and go on his first mission – to Sarajevo in 1993.

Over the course of the following decades he would travel to sites of conflict gaining a wealth of experience working in the most challenging environments, often with minimal supplies and equipment. Chapters detail a number of these placements focusing on patients who left key impressions. As a reader it is difficult to comprehend how those who caused the injuries could inflict such pain and suffering on their fellow human beings.

Much of the book focuses on memorable surgeries carried out in makeshift hospitals. With a constant stream of all but destroyed bodies arriving, decisions needed to be made quickly about who it would be worth treating. On one occasion a man required every unit of blood available in the city. When he subsequently died the question of how many others would die for want of a blood transfusion lingered.

On a mission in Africa Nott treated pregnant girls as young as nine years old – victims of rape whose pelvises were not developed enough for full term births – who were brought to the camp hospital after many hours in labour to have their now dead babies removed in an attempt to save the mother’s life. In Afghanistan he witnessed the public spectacle of punishments meted out under Sharia law, Taliban style.

“women being stoned to death after being buried up to their necks in sand; women being placed beside a wall they had built with their bare hands and killed after a truck was driven at the wall at high speed. […] I was astonished and sickened by the cruelty that one human being could bring to bear on another, and it filled me with revulsion. The football stadium was full of people watching and I wondered what they all felt. Were they completely inured to it?”

The impressions left by such monstrous behaviour increasingly affected the doctor when he returned to his job in London. During a private consultation he all but lost it when a patient complained about how she suffered due to unsightly thread veins.

On a mission in Aleppo, Nott noticed that patients would arrive with similar injuries that changed each day.

“Abdulaziz told me that he’d heard that the snipers were playing a game: they were being given rewards, such as packs of cigarettes, for scoring hits on specific parts of the anatomy. […] This sick competition reached its nadir towards the end of my time there when it appeared that one particularly vicious and inhumane sniper had a new target of choice: pregnant women.”

The author treated several of these women whose babies had been shot in utero. It was this experience that finally drove him to try to publicize the horror of what was happening in Aleppo once he returned to London. The media showed interest and he began to offer interviews and share pictures taken. Harnessing his increasingly public profile, Nott sought to help those now trapped and in imminent danger in Syria.

Given the horrors recounted, this book could be challenging to read yet much of it comes across as hopeful due to the determination of the medical teams to continue to offer treatment whatever else is happening in their vicinity. Nott includes many instances when his efforts were unsuccessful, and examples of risks he took that with hindsight were foolish. He does not paint himself as a hero but rather as a man who relished the adrenaline rush of danger. Nevertheless, it is hard to do anything but admire the tenacity and bravery of all the medics.

The writing is precise and succinct but retains a compassion for the suffering of those whose lives have been stripped to a struggle to survive in unimaginable conditions. Details of the medical procedures are fascinating and described in accessible language. And yet, with so many wars included there is a feeling of despair when considering what man is capable of inflicting. Nott admits that his work has left him in need of therapy for PTSD.

I mentioned that the stated purpose of the book was to raise awareness and in this it succeeds. It is, however, difficult to know what to do with such awareness in a world controlled by the egocentric – venal governments willing to turn a blind eye to atrocities carried out by extremists. Whilst being a moving, balanced and insightful account of the horror of war and the commitment of medics, it is also a harrowing read.

My copy of this book was provided gratis by the publisher, Picador.

Book Review: Hard Pushed

Hard Pushed: A Midwife’s Story, by Leah Hazard, provides a timely reminder of how valuable the NHS is, and of the appalling demands currently being made of front-line staff. The author is a working midwife and shares stories of cases she has dealt with, and the conflicts regularly faced due to the spectre of rules and a lack of resources. It is not, however, polemic. Written with grace and generosity, this candid memoir presents the business of birth with clear-eyed understanding of expectations and reality. There may be a great many bodily fluids to contend with but bringing a baby into the world remains an emotional event.

The births described are those that were memorable, mostly due to complications, many unforeseen. These include: the young mother who is still a child herself; the woman who became pregnant thanks to IVF and whose partner now has cancer; the rape victim; the prospective mother suffering a serious illness. Between each case study are notes in which the author muses on such subjects as: thwarted assumptions; being human; the many challenges of the job. She has to deal courteously with colleagues who have contentious opinions. When mistakes are made they can have far reaching consequences.

The author writes of a new mother whose own mother undermines her confidence with well-meaning suggestions, and how a midwife must support but never interfere. She writes of: birth plans, birthing pools, FGM and death. She describes the mind-numbing exhaustion faced by staff working lengthy shifts in over-crowded wards where medical emergencies leave labouring women unattended. The professional script she must follow is designed to both minimise patient concern and protect the midwife.

The intense and unpredictable daily demands lead to regular burn-outs, something to which the author is not immune. The job takes a physical and mental toll that can be a challenge to sustain.

This is a fluently structured and fascinating account of a job that, even as a mother of three, I had not fully appreciated. I feel angry on behalf of these hard working professionals for the way our healthcare system is being managed and funded.

Yet the warmth and compassion with which this book is written provides a beguiling and entertaining read. The balance achieved is impressive – recommended for all.

My copy of this book was provided gratis by the publisher, Hutchinson.

Book Review: Admissions

Admissions, by Henry Marsh, is a searingly honest memoir by the retired brain surgeon who brought us Do No Harm (I have yet to read this earlier book). It is a somewhat regretful looking back on cases the author has worked on, mistakes made, and the balance neurosurgeons must acquire between confidence in their abilities and concern for the patients whose lives can be so drastically altered by their interventions.

Marsh resigned from his position as a senior consultant at a large London hospital when he felt the respect that doctors once enjoyed had been undermined by the target culture and petty rules imposed by bureaucrats granted the power to allocate funds and decide who gets treated in the modern NHS. Marsh continued to travel to Nepal and the Ukraine, where he assisted colleagues who ran private teaching hospitals, although he was questioning the usefulness of his roles here as well. This is a tale of facing up to a life approaching its end, for the author as well as his patients.

Although enjoying many successes, brain surgery carries the risk of patients surviving but with a questionable quality of life. Decisions on whether to operate must take into account the probability of such outcomes. Saving a life may leave relatives burdened with round the clock care of a loved one who has little awareness or, perhaps even worse, aware but catastrophically damaged. Modern sensibilities have made honest discussions about the benefits of death difficult. There is a reluctance to accept that medical intervention merely postpones the inevitable.

Having watched his parents die, from cancer and dementia related illness, Marsh has a pragmatic view of his own mortality. He also struggles with what certain colleagues may regard as professional arrogance and ponders what he will become when he is no longer a renowned surgeon. He recognises that he has, at times, made poor decisions and behaved badly. Even the satisfaction found in his work has been lessened by what he has learned of the reality of patient outcomes over his long career.

Marsh’s musings on the way the brain works and the effect on the body are fascinating. His views on psychosomatic illnesses, whilst in line with well researched medical opinion, are likely controversial amongst patients who demand a physical explanation for their very real suffering. In the chapter, Lawyers, he discusses whiplash injuries.

“An English woman had been involved in a minor car accident in the USA while on holiday, and had subsequently seen me as a patient about her ‘whiplash’ symptoms. I had confirmed with an MRI scan that there were no significant injuries to her neck […] Patients develop an array of aches and pains and altered sensations in their necks and arms which do not correspond to any known pathological processes […] It is well known that these syndromes do not occur in countries which do not have any legal recognition of whiplash injury as a consequence of minor car crashes.

I used to see many of these patients every year in my outpatient clinic and it was clear to me that most of them were not consciously malingering […] With ‘whiplash injury’, the possibility of financial compensation for the victims, combined with the powerful suggestion that they have suffered a significant injury, can result in real and severe disability, even though it is, in a sense, purely imaginary. […] It is the modern equivalent of the well-attested phenomenon of a witch doctor in tribal socity casting a spell on somebody, causing the victim to fall ill, merely through the power of suggestion and belief.”

In his work in Nepal the author encounters many women suffering debilitating headaches which, when scans show no physical problems in the brain, he suggests may be down to some unhappiness they harbour in their personal lives. He explains that pain occurs in the brain but can manifest anywhere in the body, and can have a psychological rather than physical cause. Patients are unhappy if they are not offered a cure involving surgical intervention or costly medication. The suggestion that psychiatric treatment may be more effective does not go down well.

Most of the cases discussed, though, involve the removal of brain tumours. Marsh intersperses the detail of these with anecdotes from his personal life, at the time and throughout his past. What emerges is a picture of a flawed but determined individual who wishes to honestly portray how he got to where he is now.

An interesting medical memoir from an author who is not afraid to state his views, however terse or contentious. It offers a window into the world of brain surgery, and the difficulty of ageing after a brilliant career.