May has come to South London, blustery, fresh and often wet, but many Britons on the streets are sporting short sleeves and bare legs as if holidaying in the tropics. Even the hospital, stuffy and suffocating by tradition, turns out to be airy, with a chilly draught coming from the window berth I have luckily secured. Perhaps they’re saving on energy.
Our ward has a motley, shifting crew of patients. Of the languages I know, English is the only one that confers this subtly coercive title, redolent of the administrative grandeur that made it possible to run an empire, upon the bedridden malades, enfermos, bing ren.
The most patient captive is Eric, a soft, round West Indian man with a drizzle of white in his hair and beard. He has no books or magazines or telephone or visitors, but lies or sits for hours at a time in quiet contemplation. It transpires that he is diabetic but it’s not clear what else is wrong because he can’t complete a sentence. “How are you today, Eric?” the friendlier of the nurses ask when the medications trolley comes round. “I’m trying to find the um, er, yes . . .” he starts, in a pleasant, burring voice, and then fizzles out. Sometimes he slippers off to the bathroom and once or twice this triggers alarm among the nursing staff: “Where’s Eric?” they demand of the rest of us, evidently worried that he may by now be looking for the lost thought on the streets of Croydon.
Between Eric’s bed and mine lies Berhic, an elderly, inert Turk, equally devoid of any contact with the outside world or any ability to communicate with this small part of it. When the catering contractor passes through to take the daily meals order, from a menu whose options read better than they taste, there is a short, sad comedy sketch as the momentarily animated man struggles to indicate a preference with spluttering, Turkic sounds that the caterer interprets as he sees fit. Why don’t they include pictures on the menu?
A more concerted effort to communicate is made when Berhic soils the bed. A bevy of carers gather round to admonish him, telling him, in raised voices and SPEAKING VERY CLEARY in their assorted third world accents, to press the buzzer when he needs to go. How did he end up here? One of the staff tells me he lives in a local nursing home and is shipped in whenever he gets sick; but that doesn’t explain much. Just down the road are some grocery stores that burst with Mediterranean vegetables, flat breads studded with sesame seeds, chick peas, ful beans, yoghurt and goats’ cheese. Did the old man’s life have some connection with these and, if so, why is there now no residue of connective human tissue to hold his hand or speak his tongue?
The space across from Berhic is occupied by Kenny, a perky young white bantam cock, who ambles in and out with a plastic bag full of tobacco and king size cigarette papers. I befriend him in order to cadge a fag and learn, in the tattered sunshine outside, after a painful hobble to the lift, that Kenny was admitted following “a fit” in which two blokes had to sit on his chest. “So you’re epileptic?” I venture. “Oh no! It was just a fit.”
Kenny’s main pal, though, is Jeffrey, a timid, retired postman in the bed across from me. Jeffrey says he has “E coli in the blood” which caused him to collapse at home, where he lives by himself and was only spotted, in a heap on the floor, through the window. That shook him up.
Most afternoons his dad, a short man well into his 80s, sporting a scarf and black homburg, comes in to visit, passing the time sitting on the bed, feet not quite reaching the floor, reading the newspaper and eating Jeffrey’s leftover ice cream from lunch. Dad, Jeffrey says, is an “awkward bastard” who divorced the family rather early. Jeffrey is also divorced: his ex and grown-up children moved out of London and now live, separately, in a small East Midlands town. Jeffrey would like to move up there too but hasn’t told dad yet.
Jeffrey politely quizzes Kenny and we are treated to a disjointed story about a teenage girlfriend, a pregnancy, a restraining order. What’s distinctive about this is neither the tawdriness of the tale nor its narrative incoherence but the complacency of the delivery: Kenny sounds off like a social worker’s pet client, someone who’s always cooperative and speaks up in group-work sessions.
This impression seems confirmed when, apparently recovered from whatever “fit” had ailed him, Kenny is cleared to leave. His mum comes in to help fuss over his plastic carrier bags of stuff but Kenny bounces about on the bed telling all and sundry that he cannot go until provided with his week-end supply of methadone. A ‘recovering’ heroin addict, then. There’s a jurisdictional problem over the prescription, a series of loud phone calls to his key worker. The hospital pharmacist comes up to consult. And in the end Kenny trips gaily off with his grey mum, prescription in his pocket, offering me a pinch of tobacco as a parting gift.
That night after lights out, the codeine blur of sleep is interrupted by the clank of an arriving bed as a newcomer takes Kenny’s place. The man pushing the bed wears a security company uniform with a radio clipped to his belt. The new patient disembarks with no apparent difficulty and makes for the bedside chair where he assumes a grim, motionless vigil.
Morning finds him in the same position: stocky, powerful, but expansive under Jeffrey’s timorous questioning. The daintily built, ruddy cheeked ex-postie later tells me that he lay awake all night, afraid to sleep lest his new neighbour decide to suffocate him with a pillow.
“I’m an alco’olic, I am” Patrick, the new man, declaims in an accent I can’t place: Manchester? Preston? “It’s ruined me life but, there you go, I’ve ’ad enough of it.”
He’s going to make a new start, he announces; no more sleeping in doorways around Kings Cross and St. Pancreas (sic), the winters are that bad. And he’s got a great chance now because the police alcohol counsellor has given him some “papers” and made him an “appointment.”
The tea trolley trundles in, manned by a person we have not seen before. Jeffrey, Constantine and I convince him that Berhic takes his tea with two sugars. The old Turk, who appears to be getting better, flails about a bit in what might be a token of gratitude. It could equally be frustration, though.
Constantine is the man I would most like to befriend, but he is in the furthest bed from me, and it seems indelicate to chit chat across the strange public theatre of misery.
It suddenly occurs to Patrick to show the “papers” to validate his tale. But he can’t find them in the plastic bag he came with. He paces the ward inviting us to share his outrage: “They’re official papers! Printed documents!” Then out to the nurse’s station offstage. “What have yer done with them? It’s me only chance! I’ve got no chance if I miss me appointment.”
Eventually someone is despatched to the ward Patrick came from—the Accident and Emergency overflow unit, presumably—and returns with the two sheets of missing paper, which Patrick exultantly displays. One is a list of hostels and bed-sits in the Croydon area; the other, in 24 pt. text, a paragraph advising him to look out in a local park “between the hours of 9 pm and midnight” (proper police language, that) for a community group whose phone number is provided: the entry point, one may suppose, to charitable soup kitchens and doss houses.
If this promises less than a dog’s chance of going straight it still keeps Patrick happy for an hour or two. Expansive again, he shares half-anecdotes about life in Walton jail and on the streets. He claims to have spent 30 of his 57 years in prison—“all for petty stuff, mind, nothing serious” he assures us, none too plausibly.
Then another problem occurs to him: he has no clothes to wear to his appointment, only the faded hospital gown he is now wrapped in, because the police took everything. (To the incinerator, one can only suppose). And so begins a campaign to bully the staff into finding suitable apparel.
A while back I requested a bulb for the angle-poise lamp above my bed. “Maintenance” would be informed, I was told, but nothing happened for a week—and then only on the initiative of a nurse who, reminded of the problem and apparently deciding to break the rules, went off for a couple of minutes and came back with one.
Patrick’s persuasive powers seem greater, for he is bit by bit provided with a shirt, jacket, trainers. Jeffrey phones Dad, who brings in a pair of track-suit bottoms to complete the outfit. And in the late afternoon Patrick, whose stay has had no obvious medical rationale, steps into the world again to start his new life.
“I don’t suppose he’ll keep off it, will he?” Jeffrey asks, reluctant to commit to an opinion unless it is shared. Before I came, he says, there was a “real loony” on the ward one night, a bloke off the streets who brought in drink and raved away, smashed things. Jeffrey begged to be moved and they let him creep off to a spare bed in an adjacent ward.
Jeffrey is discharged a few days later after waiting many hours for his papers to be readied and for his medications to come up from the pharmacy. The afternoon before we had tittered together in schoolboy merriment at the discharge of Eric and Berhic. A wheelchair came for Eric: we bade him hearty farewells, such a sweet man he seemed, but he got no further than the nurses’ station before being sent back. An hour later an ambulance crew came and started to load him onto a trolley, but they were told that Berhic was their man, and carted him off instead. Finally the wheelchair came back for unruffled Eric. Jeffrey’s departure proves more fretful: the impatient hours reduce him nearly to tears, because if it gets any later dad will be caught in traffic and get a cob on.
The vacated beds are filled by a trio of men with ruined lungs. An elderly, South Asian looking man, his name illegible on the white board above his bed because it is too grey from use, spends only two nights. He fills them with a symphony of gurgles, squeals and rattles as breath struggles to find ways in and out. “He’s worse than yesterday! Coming home to die, essentially,” pronounces the elegant, middle aged daughter who fetches him. “Go and get the car round,” she snaps at a younger brother, throwing her pashmina shawl onto the armchair. They have decided not to wait for the forms.
Jeffrey’s perch goes to Walter, admitted from a nursing home because of CORD. “Chronic obstructive respiratory disease” he elucidates. “From smoking,” he adds redundantly. When at night he gasps for breath he thrashes about in the bed like a four year old learning to swim, yet finding enough oxygen also to cry out “Fack! Fack! Facking cant!”
Herbert, who takes Berhic’s place, is more reserved and stoical. He sits bolt upright in the armchair for 18 hours a day, with occasional shots on the ventilator, postponing the horizontal position that soon has him joining the orchestra of wheeze and spit and bubble.
Mum and the mighty stethoscope
It’s interesting how the stethoscope, which has been with us since the early 1800s, remains a badge of office in hospitals. No doubt something of the kind is useful to distinguish doctors from the auxiliary rabble; to prevent patients and their families from besieging the cleaning or catering crew with their anxieties and, perhaps, to boost the confidence of the youngest clinicians.
There’s quite a gauntlet to crawl, if you don’t arrive in Accident and Emergency visibly mangled, before you get to see anyone with a stethoscope: a cordon sanitaire of forms to be filled out, hefty porters, a po-faced ‘triage’ nurse to weed out the wastrels, dissemblers and loonies. Understandable, no doubt, but none too comforting. Notices on the walls inform the supplicant sick that there’s zero tolerance of abusive behaviour towards staff: you’ll end up in a police cell. It’s reminiscent of Ryanair check-in notices: buckle your lip or you don’t get on the plane.
The medics who finally attend me appear eminently competent. (What would I know?) Seem like nice people, too. It comes as no surprise that the supporting edifice of basic care is distinctly creaky by comparison.
In the folder at the bottom of my bed I find a bundle of forms—official documents!—recording attention to the patient. It appears that the nurses are supposed, every hour, to ask every patient five questions including, most grandly, “Is there anything I can do to make you more comfortable?” No-one has ever asked me this, or anything like it. Yet my forms are pretty much up to date—though it is clear from the even manner of their filling that they were completed in bursts, done all at one time, doubtless in a blitz of paperwork at the end of the shift.
In column after column I find the words “P/t [patient] comfy;” “P/t s/c [self-caring – ie, doesn’t need bedpan]” etc. Two things are clear: one, that I am not considered a problem patient, so need only minimal attention. (No complaints on that score). Two, that the job would be impossible for any nurse, however conscientious, who went through with this rigmarole. Even discounting the Erics and Berhics who are incapable of answering, or those who can’t summon the breath, there’s surely enough to do without inviting an hourly shopping list of complaints and requests from less patient men.
And, besides, do the nursing staff really need official reminders to try and make the patients comfortable? It must be something to do with ‘accountability,’ some patients’ charter, counterpart to the ‘no staff abuse’ policy, to make sure that everyone’s rights are ‘respected.’
My mum was a nurse (and also suffered, in later life, from bouts of the acute arthritis that landed me here; studying my feet, swollen as raspberries after a wet Spring, I am now struck by the family resemblance.) She had no politics to speak of, looked for the middle way on nearly everything, save for a fierce loyalty to the National Health Service and an uncharacteristic, visceral anger at the demon of private health care. (The crux of her case being: “If there’s an emergency it’s always the NHS left to cope; that blasted BUPA”—‘blasted’ being the most bitter invective that she would utter, apart from one or two real emotional crises when then the word ‘bleeding’ was heard to pass her lips—“That blasted BUPA just poaches all the consultants for the queue-jumpers! And it’s the NHS that trains everybody, of course.”)
As a single parent she managed for several years, just, to feed four children on the salary of a staff nurse. (Restricting herself to five cigarettes a day: one for breakfast; one for lunch; three at home in the evening.) She couldn’t become a Sister or Matron because she couldn’t work enough hours or flexible shifts. If she’d been born a generation later, or to a family that could afford to educate her, or had married a more reliable man, she might well have been a doctor. She revered doctors—who, in her day, were almost always men.
I always felt the division of labour was too sharp and hard. Experienced nurses should be given more training and clinical responsibility, higher rank and higher pay. (Can a stethoscope be that hard to operate?) Expert opinion would doubtless ridicule the idea, on the grounds of clinical standards or whatever. But I would counter that institutionalised medical care was built upon the foundations of social class, not some tabula rasa of rational management planning. It was no glass ceiling but a steel partition that separated factory manager from shop floor charge-hand, the stethoscope from the bedpan, the commissioned army officer from the NCO.
The military-medical nexus, still hinted at in nursing uniforms, was in fact quite strong. For battlefields (and warships) were also a major laboratory for medical science, bringing developments in everything from reconstructive surgery to psychiatry and even mass field trials of penicillin. And Florence Nightingale, now foggily associated with mopping fevered brows in the Crimea, was in fact a major force in public health science. As well as re-organising field and civilian hospitals on ‘sanitary’ lines (thus improving the military efficacy of the British Empire), she pioneered the collection, analysis and presentation of medical statistics, and is widely credited with invention of the pie chart.
Anyway. Growing up in 1960s Britain it was easy to believe that old barriers and privileges were on their way out. But the times unravelled in much more complicated ways. It became possible for men with ruined lungs to live longer, and for worn-out body parts to be replaced, at growing cost to the state. University entrance, especially for women, surged dramatically, opening up new opportunities that easily out-bid nursing careers. Market theology turned a vertically integrated system into one that was fragmented by outsourcing, overseen by professional managers. ("Blasted administrators," my mum would say: she thought Matrons, tempered by front line experience, should be left to run everything.) And the labour pools of old empire, in the first place, and then Eastern Europe, became a major tool of cost control: turning to people who were still prepared to work 12 hour shifts for low pay more than a century after the Factory Act (1847) had introduced the 10 hour day in British manufactories. Which brings us to the peculiar present.
Matron, who I spot only once, is a plump Irishwoman, red hair grey at the roots, approaching retirement. She would have been a newly arrived young thing in my mum’s later days.
Sister is a pleasant Zambian, rarely to be seen on the ward. No doubt she spends much time supervising things behind the bank of computers at the busy nurses’ station. Funny how effortlessly computers succeed, at home and office and everywhere, in drawing attention to the screen and away from the immediate, human environment. And there must be so much data, reports to write, buttons to click. As well as phoning the porters’ office to enquire why that wheelchair hasn’t arrived, an hour after it was ordered, and arguing the case on another line for more staff to be despatched from the agency because someone hasn’t turned up and they’re overwhelmed with patients, many of whom are “confused.”
Front line care is dominated by some rather fierce Nigerian staff nurses. One, on a Sunday shift, can be heard singing a hymn under her breath as she makes her rounds, but that’s as happy as she ever gets. One night facking cant Walter takes to pressing the buzzer, demanding painkillers and to see a doctor. (Remarkable how such a wrecked body can still sound so peremptory.) The doctor will come in the morning, he is curtly told. There is no effort to soothe him, and so for about an hour there’s an increasingly hostile back-and-forth of pressed buzzers and sharp words until Walter passes out from exhaustion just before a duty doctor finally arrives. Wouldn’t it have been better to sit with the old cant for a while and stroke his facking hand?
Hostilities resume the next day when Walter discovers that his routine medication has been changed. “But I always get it!” he screeches, “That’s what they always give me!” Papers are waved —more official documents—to prove that these are doctor’s orders, but he is not mollified. Pleasant Sister has to come along, and does a better job of explaining things. Doubtless such communication skill aided her promotion: away, alas, from the patients who need her reassuring touch.
Another medication spat breaks out when a new, young arrival, whose well-to-do belongings are still being unpacked, spits across the floor a mouthful of pills he has just been handed. “I’m not supposed to be on those any more!” he sobs, in a shrill, rising register. “I told them downstairs!” And then: “I was here five weeks ago and I know what you’re like—you’re all just stupid!”
It is a shocking outburst that leaves the Nigerian nurse in charge of the meds trolley motionless for several moments. The offense is amplified by the fact that the patient’s mum, who has a disturbing, lifeless quality of settled resignation, barely notices the fracas. She just gets on with the task of unpacking a banquet of posh sandwiches, fruit juices, yoghourt drinks. Is there a cool place that these could be kept, she is asking one of the auxiliaries, who takes a long time to understand, but finally offers space in the caterers’ fridge. To which, contemptibly, the mum responds: “But will they be safe there? Other people won’t take them?”
All the signs are of a spoilt brat who deserves a smack in the mouth; a judgment I revise only gradually and grudgingly over the next couple of days as it becomes clear that, whatever else is wrong with this young man, he is HIV positive and far from reconciled to the fact.
The Nigerian nurse must have known that. (But maybe not: despite the computers, information flows seem sludgy). She must, though, have endured hundreds of similar tantrums and bitter, displaced words, for she is no youngster. Why then that striking immobility of a person caught between outrage and hurt, pretending now to busy herself at the end of the ward, to regain her composure? Are there no default response modes to slip into?
But perhaps that’s too much to expect. Despite the uniforms, the social norms of Croydon seem to have pretty much frayed away. That’s the point, I guess, of trying to establish care norms with forms and check-lists, but I rather doubt the prospects for codifying compassion. God or Allah might command us to respect and love each other, but no human resources manager or human rights lawyer can. And we can’t expect much if we keep passing the burden of care to people who we’re not prepared to pay decently. In the debris of messed up lives and bodies they have to deal with, I rather doubt that the nurses here—many so far from their own kin—feel much respect for their clients.
I worry for the younger ones. Surprisingly—for I thought their labour pool was supplanted nowadays—there are a couple of trainees fresh from the Caribbean, to judge from accents not as yet souflondonified. They are quite friendly but diffident, not yet toughened up or sure what to do. Usually, they get to stick the digital thermometers in patients’ ears and hook them up to the machine that measures blood pressure, heart rate and oxygen absorption. A great piece of kit, no doubt, but I can’t help feeling that it deters the nurturing of other skills, reducing touch and turning the attention, again, towards the screen and away from the jingshen, the human being inside the patient. And apart from that the main thing the trainees seem be learning is to breathe through their mouths while wiping up shit.
Still, I guess it’s a good deal for them: put up with this for a few years and they’ll maybe be able, to my mum’s deceased annoyance, to go and work in a private hospital or upmarket care home surrounded by lawns.
An interesting development is the presence of male trainee nurses. They are much less diffident and, on this male ward, at least, they introduce a probably useful dose of ‘You all right, mate?’ jauntiness. One, who claims to come from Dubai (but later modifies this to say he has family there—as he does, also, across much of Europe and North America), seems especially gifted at creating the impression that he’s not really doing anything except hanging out. That’s okay, I guess. If we can't have mum’s tender touch let us at least be jaunty.
“What are you doing there?” snaps a staff nurse at an unobtrusive young man who appears one afternoon in the chair that Patrick, and Kenny before him, had occupied.
This is V. Not, it turns out, a refugee who has sneaked in from the street but an officially documented new patient, who seems to have an unhappy knack of being overlooked. (He has two Sri Lankan names: both beginning with V, both more than long enough to twist my tongue and both illegible when scrawled on the grey board, where they barely fit.) Somehow the system also failed to take his supper order so I donate a packet of biscuits, and hear his story in return.
He has a massive pain in the neck, dating, he says, from two Decembers ago, when his knack for unobtrusiveness let him down. He descended from his bedsit early one morning when there was a light covering of snow and was promptly beaten up by a couple of men who were in the process of robbing the newsagents next door and mistook him for a member of the ‘pakki’ proprietor family.
I can’t get over the thought that his assailant might have been Patrick. Herbert, the stoic with shredded lungs, used to be a jeweller whose small shop was once robbed at gunpoint. That couldn’t have been Patrick: too “serious” and organised; but storming a pakki shop for a few bottles of spirits and a pocketful of small change from the till is well within the realms of imaginative possibility.
While V was recovering in hospital he was contacted, he says, by something called Victims' Support, which promised to make an application on his behalf to the Criminal Injuries Compensation Scheme. But months passed and he heard nothing more. When he tried calling Victims' Support the line was dead. It transpired that their Croydon office had shut down, probably because of government funding cuts.
The neck kept troubling him, he was back and forth to doctors, and couldn’t manage his regular work as an accounts clerk. Last November, thinking again about the compensation, he contacted a solicitor who gave him the number for the Wandsworth branch of Victims' Support. They told him to make his own application to the Scheme, which he did. He shows me a letter, dated only a week or so back, telling him that he is ineligible because he applied too late. He has the right of appeal, the letter notes—fill in the appended form, continuing on a separate page if necessary,and it will be dealt with “by one of my colleagues.”
“One of my colleagues” indeed! How fair is that? Incensed by this example of bureaucratic indifference I spend an hour helping V pen an appeal that continues over several separate pages. For all I know his pain—which I can’t help overhearing an earnest consultant next day, behind the fake privacy of the hospital curtain, describe in considerable detail as an acute inflammatory rheumatism, a bit like mine—may have nothing whatsoever to do with Patrick’s fists or anyone else’s. But that’s no reason to allow some pipsqueak in a Glasgow office to overlook the possibility with no further investigation. Wankers!
I am, it seems, getting better.
Time to go. My only regret is that I never did get to know Constantine: a mild, refined man, also of Sri Lankan origin, who studied psychology and sociology in London and then worked for many years as a behavioural psychologist with local councils. In his fifties he had a couple of heart attacks, took early retirement and then joined a jazz band as a bassist. He has a string of interesting visitors from all points of the cultural compass, making his bedside an oasis of civility in the surrounding mess. That heart, though. He must be fearing for his life.
It’s the fear of pain and death that makes us submit to medical authorities. No doubt there’s more reason to trust them now than in the days when they applied leeches and prescribed bleeding for fever. Yet you need patience not only with the illness but also with the system. Mine is running out and the system can’t do much more for me. It’s been a fascinating stay, far better than watching TV, or even the live theatre I had travelled all this way to take my grandsons to. But I am happy and grateful to hop off at last with a pair of crutches and a packet of paracetamol.
June 2013, Kigali