Richard Smith’s first days as a doctor

Richard Smith The Student BMJ is asking, via Twitter, for accounts of people’s first days as a doctor, and their request has for me brought back painful and partially suppressed memories. I started in the Eastern General in Edinburgh on Sunday 1 August 1976 and experienced my first death from medical error on the Monday. Maybe this explains the rest of my career—as an editor and busybody, rather than practising doctor.

I wasn’t totally terrified on that Sunday as I had done a couple of locums, but I was painfully aware of my many deficiencies. Interestingly in retrospect, I saw those deficiencies as entirely my fault. It never occurred to me that it was a failure of the system to leave somebody so inexperienced with so many responsibilities. Indeed, I knew about body systems but never had considered that the hospital might be a system.

That first day was quiet. My main job was to admit a woman in her early 40s who was coming in to have a specimen of bone marrow taken from her sternum. She was being investigated for pernicious anaemia. Such a patient would not now be admitted, and I don’t think that anybody takes bone marrow from the sternum anymore. This story explains why.

I don’t remember the woman well, but I think of her as ordinary and essentially well. She certainly wasn’t sick. I think that she was a mother. She was under another consultant, and so I didn’t see her again until the following day.

The other doctor, Phil, who had also just started, was responsible for doing the sternal puncture, and because he had done several as a student he got a medical student from Ireland to do it. She was rather tentative and didn’t manage to draw any marrow. So Phil took over and rapidly filled a syringe with marrow.

Seconds later the woman “fainted.” It was rather a heavy faint—so they took her blood pressure, which was initially normal, and did an ECG, also normal. I was doing a ward round with my consultant, and he went over to look at the woman. It seemed odd that she should be so deeply unconscious after a simple test, but he didn’t think it necessary to do more than monitor her.

Slowly people began to realise that something terrible had happened. The senior consultant arrived and immediately grasped the seriousness of the woman’s predicament. Now her blood pressure was beginning to drop. The most likely diagnosis was that the needle had gone right through the sternum and penetrated a major artery. So it turned out.

The woman was rushed to the intensive care unit, and cardiothoracic surgeons were called from the Royal Infirmary, about four miles away. The surgeons opened her chest, but it was too late. She exsanguinated.

I’m not sure what happened to the Irish medical student, but Phil, who seemed remarkably unfazed by the whole experience at the time, subsequently became an anaesthetist, an alcoholic, and a drug addict. He went to prison for driving while disqualified, was struck off, and died more than 10 years ago. All this may have been nothing to do with the death of the woman but more with his drinking as a student. We dissected the same body, a great bonding experience, and he spent most of his first term at medical school trying to drink 100 pints of beer in a week. The first time he got only as far as the high 80s but the second time he made it. He was a laugh, was Phil.

ebook for graduates

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