‘Expect the worst, but hope for the best.’
It’s a phrase I use quite often. Sometimes I vary the order in which I say it, depending on the situation and, let’s face it, how many times I’ve said it that particular day. Some people might call it managing expectations. I call it common-sense – a quality which, my mother believes, is really the only thing a good doctor needs. I weakly try to convince her that things like knowledge and skills matter too, but have to admit that, as usual, she has a point.
When I wrote my first blog, about death, I was overwhelmed by the responses from those with whom it resonated. I still spend a lot of time dealing with the end of life. One of the comments was from a physician colleague and Twitter friend and quoted the book of Common Prayer – ‘in the midst of life we are in death’. And I felt that the converse must surely be true – that even in the midst of death we are in life. So perhaps I should write about life, for a change.
I first heard the phrase ‘expect the worst, hope for the best’ on the admissions ward in the district general hospital where I worked as a medical house officer. It was spoken, in the early hours of a weekend morning, by an experienced and wise staff nurse who stood outside the curtains surrounding one of the beds in a six-bedded bay. I was behind the curtains, trying to put a drip into an elderly patient. The patient had – I suspected – acute left ventricular failure. Their bed was illuminated by an angled wall lamp with a faulty hinge. This was throwing an inadequate pool of light which reduced my world to the patient’s forearm, on which was etched a network of uncertain veins, and the cannula in my own unsteady hand.
The nurse was explaining to the patient’s family that the situation was uncertain, that they must not be surprised if things didn’t go well. ‘I’m sure the doctor will have a word with you about things when she’s finished in there’. My world broadened out again as the cannula slipped into a vein, and I injected the frusemide and diamorphine that were drawn up in two syringes in the kidney bowl next to me. I stood up, and they looked at me expectantly, stoically. I repeated the phrase I had heard the nurse use. It struck me as kind yet realistic. They seemed content with my explanations and I left them sitting at the bedside, backlit by the same crooked light, and moved on to the next task.
The next morning, on the consultant ward round, I walked into the same bay and then out again, thinking I was in the wrong place. I had seen a patient, sat up in bed, eating toast and drinking a cup of tea. I did not imagine that this could be the moribund patient I had treated in the previous night’s darkness. But it was. The treatment for heart failure had worked and I was able to feel a profound sense of achievement, denied to many of today’s newly-qualified doctors by the advances of ACE inhibitors, coronary stenting and the European Working Time Directive. The patient’s relatives stopped me in the corridor. ‘Thank you, doctor. We did what you said, we hoped for the best, and it worked’.
I, like many doctors, self-critical and insecure, spend a lot of energy thinking about times when things don’t go well. But if I allow myself to think less critically, the memory of patients I have helped, even cured, come towards me out of the depths, like the opposite of ghosts. There has been the very occasional moment of brilliance – a rare diagnosis in a young drug user, a timely HIV test, a quick intubation, a wide-bore cannula into the second intercostal space. But most of my patients get better despite me, not because of me, really.
I remember as an SHO the young father after his first cycle of chemotherapy, collapsed in the ward treatment room, lucky enough to be in front of a haematology consultant who recognised overwhelming sepsis and murmured life-saving instructions to me whilst kneeling on the floor with his hands beneath the patient’s head – ‘cannula, now, no, not that one, a grey one. Gelo – squeeze it. Get some taz, give it to the nurse. Thank you. Now some adrenaline. Yes, from the crash trolley. Not all of it, just a mil. That’s it. Good.’ I found it hard to look at this patient when he returned to the ward, dressed in a suit, after he finished his last cycle of chemotherapy. All I could remember was the time that he lay on the tiles, his life literally in our hands. It felt uncomfortable, a reminder of the huge responsibilities that my seniors seemed to bear so lightly.
I remember the patient who was already on the Intensive Care Unit of a big teaching hospital when I started my job there, a middle-aged patient with pancreatitis and respiratory distress syndrome. Their spouse sat by the bedside, expecting the worst but hoping for the best, keeping vigil next to a bedside locker on which was placed a framed photograph of the two of them laughing at their recent wedding anniversary party, unaware of the horrors to come. They made an elegant couple, at odds with the broken pair – one in the bed, one in the chair – before me. The patient progressed very slowly – one step forward, two steps back, a line infection here, a ventilator-associated pneumonia there. Weeks passed. I went on leave, I don’t remember where, and when I returned the photo was gone and another patient lay in the bed. I presumed that the patient had died.
A fortnight later, a familiar figure appeared at the end of the unit, pushing an unfamiliar figure in a wheelchair, a scarf around their neck to hide the scar from the tracheostomy. It was my anniversary couple, coming to bring us chocolates on their way home from hospital. I was overcome with emotion, and had to hide in the staff room until I was sure that they had gone. The realisation dawned on me, cowering amongst the lockers, that making people better was more often than not a hard-won series of tiny, incremental improvements rather than a single heroic act.
And I remember, more recently, two patients we discharged from hospital on the same day. I had had the ‘expect the worst, hope for the best’ chat with both families. One was a very elderly patient who was not expected to survive but did, thanks to firm but gentle care, nurses missing their breaks to give antibiotics on time, staying late to ensure that ventilators were set up, physios going beyond the call of duty to shift stubborn phlegm. The other was a younger patient with a complex series of problems, with whose family I had chatted daily, shrugging my shoulders, tilting my head, pursing my lips, until the day when I looked behind the curtains and had the same sense of disbelief and relief I remembered from that ward round many years before.
I went home at the end of that particular day feeling a sense of achievement at life, not death. My eldest was at Cubs and the baby was in bed. I sat with my middle child on the sofa. ‘How was your day?’ Fine, she said. ‘What was the highlight of your day, Mummy?’ she asked me. A clever ploy, a question I often ask her to avoid the ‘fine, don’t know, can’t remember’ responses to the standard how was your day. I told her that I had managed to help a patient get home who I didn’t think would make it, who had a very difficult journey, who needed lots of help but who got there in the end. ‘Like Dorothy?’ she asked. My brain crunched the gears between home and work. Yes, I agreed. Like Dorothy. And I was reminded of the section of her favourite film where the travellers find their way out of the poppy field and head towards the Emerald City. The music for that section, I found out only recently, is called Optimistic Voices. Sometimes, hoping for the best really works.