(2013) Looks Could Kill (10 page)

“Thank you, sir. Externally, the deceased was a white male of average build in a good nutritional state and with no abnormalities or other distinguishing features. On examination of his heart, there were areas of ischaemia in the inferior and anterior myocardium, and thrombus completely occluded the right and left coronary arteries.  I found no abnormality in his lungs. Examination of the organs in his abdominal cavity revealed no abnormalities. His brain was similarly unremarkable. My opinion was that the deceased died as a result of myocardial infarction.”

“Thank you, doctor. I have no further questions for you. You are excused.” 

Dr Singh left the witness box and walked to the exit of the courtroom.

The coroner turned to his papers and briefly wrote something. “Dr Jones, would you please come forward and give your evidence.”

Emma was dressed in a black trouser suit and looked suitably professional. She walked forward confidently, entered the witness box, and swore on oath.

“Would you please tell the court your name, qualifications, job title and place of work.”

“My name is Dr Emma Jones and my qualifications are Bachelor of Medicine and Surgery. I am currently employed as a senior house officer in general medicine at the John Michael Hospital in Rochester.”

“Thank you, doctor. I have your report in front of me. Perhaps you could take us through it.”

Emma took a deep breath and started reading from her notes: “Mr Williams was admitted to the Coronary Care Unit at St Edwards’ Hospital on the 2
of February 1989 from the Accident & Emergency Department where he had presented with severe chest pain. An ECG was performed which showed changes indicative of ischaemia in the inferior myocardium, meaning that he had had a heart attack. This was confirmed by a high troponin level in his bloodstream. He was given aspirin in the A&E department to help dissolve clot in his right coronary artery and he was then transferred to the Coronary Care Unit for monitoring. I came on duty the following day as the new house officer in the Coronary Care Unit. I was asked by staff nurse Simmonds to see Mr Williams as the ECG monitor showed that his heart was in atrial fibrillation...”

“Doctor, could you please explain to the court what that signifies?”

“It’s when one of the chambers of the heart receiving blood – the atrium – stops contracting properly and starts fluttering. This may happen after a heart attack and it can result in further abnormal contractions – such as ventricular fibrillation – which can be fatal.”

“Thank you for that helpful explanation, doctor. Please continue.”

“I went to Mr Williams’s bed and asked him how he was feeling. He was very pale and complained of feeling tired. I told him that he might need to be on extra medication to control his irregular heart beat but said that I wanted to wait until the ward round, which was due to happen shortly. I waited for about an hour and then phoned Dr Odulele, the senior registrar. He told me that there would be no ward round as the consultant was on leave and he was in the outpatient clinic. He advised me to commence an intravenous infusion of amiodarone, which is a drug used for treating cardiac arrhythmia. I then spoke with staff nurse Simmonds and together we set up the drip. She told me that she would monitor his response to the drug and hand over to the night staff. When I came on duty the following day, I was informed by staff nurse Simmonds that Mr Williams had passed away during the night.”

“Thank you, doctor.” He paused briefly to look at his notes. “Am I right in thinking this was your first day on the Coronary Care Unit?”

“That is correct, sir.”

“So you might not perhaps have been fully aware of procedures for treating certain cardiac conditions?”

“Yes, I suppose that is true, which is why I phoned to speak with my senior registrar, Dr Odulele.”

“Quite. Tell me, doctor, do you think starting the new drug – the amiodarone – any earlier might have made any difference to the outcome?”

“To be honest, sir, I don’t think so.  Mr Williams did have extensive damage to his heart…”

A man suddenly stood up from the public area of the coroner’s court; Emma recognised him as Mr Williams’s partner. He started shouting and pointing his finger at her: “You’re lying, you bitch. You killed him! If you’d treated him sooner he’d still be alive! You killed him!” He was persuaded to sit down by people either side of him.

“Thank you, doctor,” said the coroner. “I have no further questions for you. I think it would be best if I excused you. We will adjourn for ten minutes.”

Emma hurriedly collected her papers and left the witness box, wanting to run from the court, feeling that Mr Williams’s partner and the rest of the court were staring at her and blaming her for the death.

She went into the toilet outside the courtroom and sat down crying. After a while, she took out a small clutch bag from her shoulder-bag and opened it. She removed a razor, steri-strips and a plaster. She lowered her suit trousers.  She tested the sharp edge of the razor against her thumb and then made three parallel incisions at the top of her inner thigh. She drew the edges of the wounds together with the steri-strips and then applied the plaster. After making sure that there was no blood on the floor, she left the toilet, checking that no-one from the courtroom was outside.

Emma left the court building and found a café around the corner where she bought a black coffee. A short time later, Julia Simmonds came in and sat down opposite her.

“Sorry, Emma, that was really out of order.” She took her hand.

“It’s just so unfair, Julia. I called Brian to come and see him but he wouldn’t and I even went through things with his boyfriend. I mean, what more could I have done?”

“You couldn’t, Emma, you really couldn’t. Look, you’ve got nothing to worry about. If anyone’s to blame, it’s Brian, and I’m sure that’s what the coroner is going to say.”

“Thanks, Julia, but it was just so horrible being blamed.”

But whatever Julia said, and whatever the conclusion of the coroner, Emma still felt as guilty as hell and she was sure she could have done more.

February 1992

“Dr Jones,” the Chair of the Appointments Committee asked, “I wonder whether you might describe to us a couple of clinical cases that led you to changing your clinical practice.”

Emma knew that this sort of question was likely to come up at her interview for a senior registrar rotation, so she didn’t have to hesitate much before responding.

“Well, there are two cases that stick in my mind and both were on the first day of my two house jobs,” she said. “The first was an elderly man admitted for cholecystectomy who had alcohol dependence. I started him on an alcohol detox but my consultant crossed it off the day of surgery. He went into withdrawal postoperatively and stabbed a nurse and another patient. I learnt from that to stick to my guns and prescribe when appropriate. The second case was a young man with a MI admitted to CCU who went into AF. I put off starting him on amiodarone because I thought a ward round was going to happen. It didn’t and the registrar wasn’t much help, which meant that the drug was started late. Unfortunately, he died overnight following a further MI. I learnt from that to insist on a senior opinion if I’m not sure what course of action to take.”

“Thank you very much, Dr Jones; very interesting cases,” said the Chair. “I think that’s all the questions we have for you. We’ll let you know later this evening whether you’ve been successful. I believe we’ve got your home phone number.”

Emma thanked the panel members and left the room.

“Very interesting,” said the Chair, “and not a little disturbing. It does sound as if she had rather poor supervision in those jobs – just four years ago, I believe – and I would hope that supervision is much better now. She also seemed remarkably detached when talking about those cases, and I’m not sure that’s a good sign.”

“I agree, point taken,” said the Medical Director. “They were good cases and I think she demonstrates sound reflective practice and appears quite caring. I think she’d be a good pain physician. I vote that we select her for the next rotation entry point.”

“Okay, I have some concerns, but agreed,” said the Chair. “Will you ring her this evening?”

“Hello, is that Dr Emma Jones? Oh, excellent. This is Dr Michaels from the appointments committee. I’m delighted to tell you that we can offer you a place on the higher rotation in pain medicine. Well done, very well done.”

So Emma was on the next rung up the career ladder. This time, there’d been no wool pulled over anyone’s eyes; she’d been honest and direct in all the answers to their questions. 

Thinking back to her childhood and adolescence, Emma found it reassuring to see the changes she’d achieved in her development, going from a spiteful child to manipulative adolescent, and then finally, to a relatively honest adult.

The rotation in pain medicine lasted three years and was divided up into a year each in palliative care, pharmacology and oncology. Aside from the clinical attachments, she also needed to plan a research project and some courses to supplement her clinical skills. She decided that cognitive behavioural therapy would be the best option to give her skills she could use in her pain management work and in her research.

Emma signed up on a one-year, part-time CBT course held in Oxford. Part of this involved seeing her own patients under supervision and so she contacted the liaison psychiatry consultant to see whether he could identify a patient for her to see. A month later, Emma had a call to say that there was a 19-year-old patient for her to see and that an appointment had been made for the first session.

August 1993

“Hello, you must be Sylvia. I’m Emma. Please come on in.”

Emma led the patient into the consulting room and completed a quick assessment whilst she was walking in with her. Sylvia was roughly the same size as her and wore a rather old-fashioned purple dress that went way below the knees with sleeves that were buttoned up at the wrist. Her shoes were flat and well-worn. The bag that she was carrying was canary yellow in colour and seemed either to have been chosen in haste or deliberately to clash with the rest of her outfit. She was looking down at the floor and avoiding eye contact.

“Okay, Sylvia, as you probably know the idea with CBT is to help you build on ways that you might already have to deal with problems that make you feel bad about yourself,” explained Emma. “And if you cope better with the problems, then you should feel better about yourself. Does that make sense?”

“I suppose so,” said Sylvia, very softly.

“Perhaps the best place for us to start is to make a list of your problems. Do you think you could do that?” asked Emma.

“How long have we got?” asked Sylvia, still speaking very quietly.

“Just 45 minutes, so it’s very important that we work together to get the most out of the session,” said Emma.

“Well, there’s this to start with,” said Sylvia, undoing her left sleeve and pulling it up to show an ugly latticework of thick scars.

“Okay, that’s certainly one problem to start with and I’d like you to write that down on this piece of paper. Where do you want to put that on the paper: top, bottom or middle?” asked Emma.

Sylvia wrote ‘CUTS’ and put it almost at the top of the paper.

“That’s good, so what problem comes next?”

Sylvia pointed to her head.

“Does that mean how you feel about yourself or is it about feeling sad?” Emma asked.

“Both,” said Sylvia.

“Okay, Sylvia, you write down those two problems on the piece of paper and put the words where you think they should go.”

Sylvia wrote ‘SELF’ above ‘CUTS’ and ‘SAD’ some way below ‘CUTS’.

“Is there anything else you want to write down, Sylvia?”

Sylvia pulled up some of her hair and pointed at a number of small bald patches which looked to Emma like signs of trichotillomania.

“Okay, Sylvia, you add that to the list as well.”

Sylvia added ‘HAIR’ and put it right at the top.

And so the session continued until there were seven items on the list.

“Now, Sylvia, we’ve almost come to the end of the first session and what I want you to do is to concentrate on the first problem: the hair pulling. What happens after you’ve pulled your hair?”

“I feel horrible and ugly and I cut myself.”

“Okay, and what do you think makes you pull your hair?”

“Being on my own.”

“Okay, so what about if I gave you some homework for next week so that you’re not on your own all the time? Let’s say that you go to the library for a couple of hours every day to read where you’ll be with other people but you won’t have to talk to them. Do you think you could do that?”

“I’ll try,” said Sylvia, looking up for the first time in the session.

“Good,” said Emma. “So, I’ll see you next week; same time, same place.  By the way, that’s a nice bag you’ve got there; it’s an unusual colour.”

“Yes, I’ve had it for ages. It reminds me of being in a field with buttercups and feeling safe.”

Emma showed Sylvia out. She took a deep breath and decided that she was glad she wasn’t doing CBT full time; that first session really was like getting blood out of a stone. It was also just too close for comfort, although Emma’s self-harming happened very rarely these days. She thought about the lemon bag and the ‘feeling safe’ and came to the conclusion that there was still a lot more of the iceberg beneath the surface. And it was a shame you can’t do something about toxic parenting or fathers who stray from the marital bed at night.

October 1993

Sylvia seemed to be making progress despite Emma’s relative inexperience in CBT. Emma’s supervisor thought she’d hit the nail on the head with the observation about the yellow bag but agreed that diving into the depths of what that meant shouldn’t be hurried.