Rage

The injustice and cruelty of the medical system triggered my childhood trauma. Confronted by an authority figure, who was an appalling bully, I began a quest to transform the system.

(Trigger warning: the beginning of this chapter contains a story of childbirth trauma)

“Beep, beep, beep, beep!” 

The sound of my pager is urgent and relentless, rousing me just ten minutes after I fell into an exhausted sleep in the doctor’s on-call room. I am the junior resident anaesthetist in the maternity unit of a major British teaching hospital and this is my second day and night of continuous duty.

The demands of the job are relentless; back-to-back patient assessments, inserting intravenous lines, administering epidural injections for pain relief, resuscitating collapsed patients and giving anaesthesia for emergency Caesarean Sections.

While most births are routine and safe, the risk of disaster is ever-present. I have seen babies die and young mothers lose their lives. Such catastrophic events can unfold at terrifying speed.

Despite my lack of experience, I am in sole charge of emergencies at night. In theory, I am a trainee working under supervision but in reality, my consultant is asleep at home over half an hour away. This is criminally negligent but it is how the system works. A similar story is playing out in countless other hospitals.

As I struggle back to consciousness, I find myself flat on my back where I fell unmoving onto the bed, still dressed in scrubs with the room lights blazing. I lever myself up and thrash around in confusion. I am sweaty and dishevelled; my hands tremble and my head is buzzing. 

The pager screams at me as my stumbling fingers struggle to find the button I must press to read the message. I see the words “Code Red” and leap off the bed. Code Red means an immediate threat to life. Dreadful possibilities flash through my mind; a cardiac arrest, a collapsed mother, a massive haemorrhage, a baby about to die… 

I lift the phone and stab at the number ‘0’ to call the switchboard. There is a dire emergency unfolding and I do not have the location. In my clumsy haste, I knock the phone onto the floor. I dial again. 

“Anaesthetist!” I spit out.

“Code Red, Delivery Suite!” the operator replies.

Flinging down the phone, I grab my stethoscope and wrench open the door, stumbling as my shoulder crashes into the door frame. Gathering my wits, I sprint down the empty hospital corridor, violently slamming through swinging doors. I charge into the maternity unit and the midwife at the central station yells, “Room Six!” I hammer on the door. "Anaesthetist!” I barge in without waiting for a reply. 

I am greeted by a scene of chaos. An enormously obese mother is thrashing around on the bed, screaming. The midwife is urgently probing her abdomen to detect the foetal heartbeat. The obstetric registrar has his hand between her legs. "Keep still!” he beseeches. 

The obstetrician must make a crucial decision; to deliver the baby vaginally or to rush the patient in for an emergency Caesarean. The frightened husband is trying to calm the mother down. A hospital orderly is squeezing into the room carrying an oxygen cylinder. The foetal heart rate monitor signals that the baby’s heart is slowing and is about to stop. My sense of dread is visceral.

“Emergency Caesar now!” yells the obstetrician. 

He pushes a consent form at the mother. “Sign now or your baby will die!” 

If we do not get this baby delivered by Caesarean in the next fifteen minutes, the baby may be brain-damaged or worse. We must gather the patient, the drip poles, the infusion pumps, the monitors and the oxygen supply and rush them all, bed included, into the lift.

Crashing through the doors of the operating room, we struggle to lift the mother onto the operating table. I lunge for the patient’s hand to save the intravenous line which is nearly torn out. Without intravenous access, I cannot administer the anaesthetic and finding a new vein in an obese patient could be impossible.

I work frantically, commanding the patient to hold the oxygen mask tight to her face and take deep breaths. We attach heart monitors and a BP cuff. The surgeon is already in scrubs as he splashes antiseptic skin prep over the mother’s pregnant belly.

If this were during the day, I would have a skilled anaesthetic technician to assist with the crucial preparations. But in the middle of the night, I am flying solo. My hands shake as I embark on the most dangerous of anaesthesia cases – one that is far beyond my skill as a junior resident. 

Anaesthesia in heavily pregnant patients is fraught with hazards, the gravest of which occurs after I inject the anaesthetic drugs and attempt to insert the breathing tube to protect the lungs. My only anaesthesia assistant is a midwife who has no training in emergency airway management. I hastily give her instructions.

In routine surgical cases, anaesthetists insist that the stomach is empty so that there is no risk of reflux. In the first few minutes of anaesthesia, it’s safe to gently inflate the lungs with a mask and bag, waiting until the muscles are fully relaxed so that we can insert the breathing tube. 

But in this case, the patient’s stomach is likely to be full and the immense pressure of the pregnant belly could cause regurgitation of the stomach contents the moment I start the anaesthesia. If the airway is flooded before I can place the breathing tube, the patient will inhale gastric acid into the lungs – a potentially fatal complication. Any attempt to inflate the lungs via a face masking this pregnant patient, may precipitate gastric reflux.

We take a gamble and get as much oxygen as we can into the patient’s lungs before I rapidly inject the sleeping drugs. My assistant pushes down hard on the front of the patient’s neck to prevent gastric reflux. I cannot place the breathing tube until the anaesthesia drugs have relaxed the muscles of the throat. It is an agonising wait as the patient’s oxygen level begins to fall.

The patient’s chest is now paralysed and she cannot breathe independently. Her life depends on my ability to place the breathing tube. The surgeon has his own priority: delivering the baby before it dies. He hurls sterile drapes over the patient’s body, picks up the scalpel and demands, “Can I start?” 

“No!” I yell.

I am struggling to visualise the patient’s airway with the laryngoscope. I can’t get the instrument into the patient’s small mouth, it is just too awkward. Her enormous breasts are falling over her face obstructing access to her mouth. If I do not complete this procedure soon, both mother and child will die.

I manipulate the laryngoscope blade with increasing desperation and manage to pry open her mouth. I advance the instrument down the throat and look for the larynx where the breathing tube must be placed. There is soft tissue bulging everywhere and I cannot find the airway passage. The instrument bruises the patient’s throat and the bleeding further obscures my view. The patient is turning blue, indicating the criticality of her situation. 

In my mind, I have an image of a dead patient on the operating table and a feeling of utter horror at the thought of being responsible for her death. I am starting to panic. Earlier, the patient’s heartbeat was racing with stress and now it is plunging towards cardiac arrest. The slow beat of the heart monitor heightens my sense of dread.

Then I remember something. Registrars in the anaesthesia department often share ‘war stories’ of past cases gone wrong. I remember a tale of a situation faced by one of my colleagues not dissimilar to this one. 

“If all else fails,” he said, “take off the cricoid pressure.” He was referring to the pressure applied to the front of the patient’s neck by the assistant. It’s a dangerous manoeuvre – there is a high risk of flooding the throat with stomach acid – but the cricoid pressure sometimes distorts the anatomy so that intubation is impossible, especially when it is inexpertly performed.

“Take off cricoid pressure!” I scream at the midwife. Suddenly, my view of the airway improves. The patient’s chin is able to lift and I can finally see the larynx. After several attempts, I insert the breathing tube into the trachea. The patient is now dark blue and on the verge of cardiac arrest. I pummel the breathing bag, forcing oxygen under high pressure into her lungs. With relief, I see her colour begin to improve and her heart rate stabilises. 

“OK,” I say to the surgeon, “You can start.” 

My heart is pounding and my hands are shaking. Concentrate, I tell myself. A few minutes later, the baby is delivered: blue, floppy and not breathing. It responds well to simple resuscitation and is soon revived. In the end, both mother and baby were unharmed. 

Welcome to the life of a junior doctor.

This terrifying event was not an isolated one; my peers reported frequent near-misses with disaster narrowly avoided through desperate measures. Scientists who study human performance observe that when subjects attempt highly complex tasks in the face of extreme pressure – including time pressure, information overload and distractions – clear thinking is impossible.

Humans are highly fallible; when put under pressure they predictably make mistakes of perception, execution and omission. Put more bluntly, they don’t see what’s in front of them, they do things wrong and they forget critical tasks. In an operating room, this can be the difference between life and death.

Surgeons and anaesthetists are human and, like all health professionals, they can make mistakes. Fatigue is one of the leading causes of human error. On this particular day, I was an inexperienced anaesthetist who had been on duty for 43 hours. Research shows that just one night without sleep impairs human performance as much as a drunk driver over the legal limit for alcohol. I am way beyond that point.

The physiological effects of extreme overwork and sleep deprivation are well understood. They include severe fatigue and body pain, mental exhaustion, heightened emotions, vulnerability, mental confusion, distorted perceptions, fallibility and frequent mistakes. These things are not ideal in a person whose task is to keep people alive during surgery.

Ten days after this near miss, I was involved in another almost as critical case. I was being set up for failure; the system was at fault but it was me who would be held responsible if a patient was harmed or died. I was being expected to provide anaesthesia for high-risk cases without adequate support while the consultant anaesthetists – who carried out the routine surgical cases during the day – would refuse to start anaesthesia without a skilled assistant present for safety reasons. 

This was happening in a major teaching hospital, where standards of practice were expected to be at the highest level, and the same system of abuse was undoubtedly playing out across other hospitals. It is as if airlines decided that night-time flights would be manned by trainee pilots with no co-pilot or engineer in the cockpit. 

I wondered what it would take to change the system and whether it would happen before one of my patients died. Some weeks later, the Chairman of the Anaesthesia Department summoned me and the other trainees to a meeting. 

The trainee’s lounge is tired and shabby. Torn magazines litter the table and plastic cups and sandwich wrappers are scattered on the stained floor. The worn and sagging furniture is in keeping with the trainees’ stained and crumpled appearance – their tired bodies melded into the grubby surroundings, their eyes downcast.

The Chairman, in contrast, is immaculately dressed in a silk shirt and tie, pinstripe suit and expensive leather shoes. Private practice has served him well. He barely perches on the edge of the table, his studied pose conveying distaste at the surroundings.

The Chairman wields great power and expects complete deference from his juniors. Career progress in this system requires that you ‘suck up’ to your seniors. It is well known that troublemakers are blacklisted In the shadowy ‘old boys networks’. Power knows its place. 

“I’m here to support you,” the Chairman intoned, smooth as silk. Yeah right, I thought.

“If you have any concerns at all, I want to hear them. I’m going to ask each of you in turn.” His gaze took us in one by one, the alpha dog making clear his intentions.

My peers stared at the floor, their blank faces concealing the distrust and resentment I knew they felt. The chairman issued his challenge to each person in turn. Nobody raised their eyes as they mumbled their response. “No problems,” they lied.

As the Chairman’s gaze approached me, my heart started racing. I was having traumatic flashbacks of the recent events in the maternity unit. Would I dare to speak up?

“Robin,” he paused. “Do you have any concerns?”

My eyes met his. “Yes,” I blurted, “I want to know when skilled anaesthetic assistance will be provided to juniors for high-risk cases at night. I’ve had two cases of near-failed intubation during emergency Caesarean, and we need support.”

I heard gasps as my colleagues held their breath. Some of them glanced up before quickly turning away. I was committing professional suicide. My face flushed as I recklessly continued. My words were pointed and sharp. My anger made me determined to name the injustice in the system.

“Why is it that during the day, senior consultants refuse to start routine anaesthesia unless there is a qualified technician present, while us inexperienced trainees are expected to do high-risk emergency cases in the night supported only by a midwife who is neither trained nor competent in anaesthesia assistance?”

There was a deathly silence while I stared brazenly at the Chairman. He said nothing but a small tic in the corner of his eye betrayed his sentiment. I felt a boiling heat in my chest. As the silence drew on, my senses contracted until there was only me and the Chairman present, our eyes locked.

Everyone in the room knew what I was saying. Emergency surgical cases present multiple anaesthesia hazards that only a skilled assistant can safely manage. If an unskilled assistant attempts to do the cricoid pressure, then the distortion of the anatomy can make tracheal intubation impossible. Expecting an untrained midwife to perform this task had almost killed my patient. 

Just as pilots don’t fly without a co-pilot, anaesthetists can only perform safe patient care alongside a trained and skilled assistant. This fact was being recognised in the standards applied during the day. It was inconceivable to me that the same standards would not be applied during night shifts, especially given the huge risks involved in employing junior residents to manage emergency cases.

I wasn’t alone in my concerns. The annual report of the UK Confidential Enquiries in Perioperative Deaths (CEPOD) had documented excess patient deaths as a result of inadequate supervision and assistance supplied to junior residents during out-of-office hours.

Still, the Chairman did not respond. He had decided to give me more rope to hang myself. His refusal to answer infuriated me and I became even more reckless.

“Do we have to wait for a mother to die before we take action?” I challenged. 

My gaze didn’t waver and I saw anger flash in the Chairman’s eyes as his mask slipped. In a smooth, well-practiced voice, he crooned, “Well, I’m sure when the new gynaecology hospital is built we might be able to cross-cover the anaesthetic assistance in a couple of years.”

Incensed by his attitude, I plunged on recklessly. 

“If I was the Chairman of the Department, I would ensure there was skilled anaesthetic assistance for trainees at night from next Monday, not in two year’s time!” 

I had gone too far. I saw the glint of satisfaction in the Chairman’s eyes.

“Well Robin,” he said, emphasising my name with a malign intent, “You seem to be having these issues while nobody else seems to have a problem?” 

He gazed around the room, challenging my peers, “Does anyone else share Robin’s concerns?”

Nobody spoke; all eyes turned away from me and the rules were clear.

“I thought not,” the Chairman said with satisfaction, a small smile on his face.

“Robin, I advise you to think very carefully about your career choice. You seem to be having a lot of problems. Maybe it is you who is putting patients at risk. Perhaps you should be reflecting on whether your practice is adequate?”

My stomach dropped and my mouth opened but no words came out. The chairman stood up, straightened his suit jacket and calmly walked out of the room. The consequences of my actions were clear; I had just gone up against an unyielding authority and, in the process, had wrecked my career prospects.

As the years have gone by, I have questioned why I was so reckless. I knew the rules of the system; trainee doctors soon learned the difference between the espoused words, ‘we’re here to support you', and the harsh reality. We also knew the consequences of challenging our seniors.

A medical career had been my dream. I had taken a brutal job in the oil industry to pay my way through medical school and I had devoted almost ten years of exhausting study and practice to my career. I was not far away from the ultimate prize of a Fellowship and accreditation as a consultant anaesthetist. All of that was now threatened by my rash, confrontational behaviour.

As well as the injustice, it was fear that had made me so angry. The two events in the maternity hospital had frightened me more than I had admitted to myself or to my wife, Meredith. These events had resurfaced an earlier memory when a young woman had choked to death in my hands while I desperately fought to save her, with no time to call for help.

Traumatic experiences like this stay with us for life. When confronted with an obese maternity patient turning blue, I experienced a flashback to this young patient lying dead on the bed. This is the nature of trauma: the similarity of circumstances triggers the traumatic memory, and we are instantly flooded with fear and stress as if we are reliving the original experience. 

Dreadful events continue to haunt us. To be responsible for the death of another human being is to tear apart your soul. Many people never recover. To continue to practice requires superhuman control, often at a terrible price. We numb, disconnect from our feelings, withdraw from others and become robots.

The human nervous system has a entire neural pathway devoted to this state of powerlessness and collapse. When confronted with an overwhelming threat, it causes us to retreat to a state of helplessness as we live with our shame. 

As trainees in an abusive system, we were primed to become helpless victims. That was the reaction I witnessed among my peers during the meeting with the Chairman. We had all experienced terrifying events during our years of training. We all knew that a mother would eventually die in the unsafe system. Wasn’t it our ethical duty to speak up? The failure of my colleagues to act speaks to the trauma and abuse of the system and their own need for safety and protection.

So why did I, alone, speak up? Why did I risk my career? The answer is rage. Long before I entered the medical system, I had experienced trauma and abuse at the hands of another cruel institution. I had faced bullies and I knew suffering. Now, here it was happening again.

Looking back, I can see this painful confrontation set the scene for my lifelong quest to make healthcare safer, more effective and humane. This became my lifelong obsession. I tried every possible strategy: protesting cruelty and corruption, redesigning patient care pathways, improving hospital systems, transforming culture, building leadership capacity, sitting on national committees and even advising the World Health Organization. 

When all these strategies failed to create lasting change, I launched an international movement for compassionate healthcare - supported by my wife Meredith – which we pursued for more than a decade. We helped many thousands of despairing health professionals reconnect to the heart of their practice and find renewed joy and satisfaction in their work. But the system stubbornly refused to change. 

Why was this?

This question led me to places I had never dreamed existed. I eventually did the unthinkable and quit my medical practice. I had discovered a world that is utterly hidden from the current medical system, a world of healing which offers amazing hope. This healing is based on a scientific theory that has yet to penetrate mainstream medical science, but which is supported by countless real-life experiences.

The work I do now is the most astonishing and gratifying I have done in almost forty years of practice. The journey here was long and arduous as I had to radically change my beliefs and who I was being. Its origins go back to my earliest experiences and a force of nature that shapes us all – childhood trauma.

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This story is the first chapter of my new book, ‘The Science of Miracles’. Buy your copy at any branch of Amazon (paperback or Kindle) or in New Zealand buy a signed copy from the author’s website: robinyoungson.com