Back to College

Although the residency that this blog sprung from ended in December, I’ve been invited back to the School of Health in Social Science for the month of May to run some writing workshops with students and continue my writing about nurses.

May is a good time to come back to Edinburgh – the light on the old buildings is beautiful, the trees are finally misting over with new green, and there are interesting talks and events happening.

Last week, I went to the inaugural lecture by Professor

Charlotte Clarke

Charlotte Clarke, the (relatively) new head of school. Charlotte’s background is in nursing, and her lecture drew on years of practical and research experience in dementia care. In the talk, she challenged the habitually negative framing of the disease, and explored how we might better support those who are losing a cognitive, linear sense of themselves, but remain as human and emotionally complex as anyone else.

Towards the end of the talk, Charlotte shared a poem she had written about an inspiring encounter with a former patient. In a short space, it illuminated the theme of the lecture with a human presence. I thought it a perfect example of the particular understanding that nurses can bring to the world through expressive writing, if they give time to it.

Here is the poem:

Ahead of His Time

1980’s

Rehabilitation ward they called it

But few ever left alive

Edward

Let’s call him that

Wordlessly seeing out his days

Silent with his fragile dignity

Early shift

Time to get Edward up

Talking – monologue

Not expecting any answer

Gardening

Edward's job in years before

Lettuce and the problem of slugs

Slug pellets, salt rings, jars of beer

Tried them all

Any suggestions?

“Don’t grow them”

A silence broken!

But instantly returns

Forever, for Edward

I don’t grow lettuce now

Such ecological wisdom

Didn’t think like that in the 80s

So ahead of his time

Few words, big lesson

That has shaped my life

Work with, not against

Thank you Edward.

First published in Gilliard J. & Marshall M. (eds). Time for Dementia. Hawker Publications, London. 2010

If dementia is something that affects your life, or you are interested in understanding more about it, I can recommend the book Keeper, by Andrea Gillies – a deft blend of memoir and scientific investigation that won the first Wellcome Prize for literature in 2009. 

This week’s inaugural lecture is by the new nursing Professor, Josephine Tonks Fawcett, reflecting on a lifetime’s experience in nurse education, which I’m looking forward to very much, especially in the light (or should that be shadow?) of the Francis Report and it’s recommended changes to the way nurses are trained. Changes seized upon and expanded by the government in recent months, as if nurses were the wellspring of hospital failure. But more of that later.

You can read my interview with the inspirational Tonks here.

The Body in Crisis

Now that I have some time to reflect back on my months at the university last year, certain events stay vivid, full of insight.

One such was The Body in Crisis event, organised as part of the ESRC Festival of Social Science in November. One of the key organizers was Susanne Kean, who I interviewed for the blog last year.

What brought me to the event was not just my interest in Intensive Care, but the fact that it would be an exploration of the experience from different perspectives, with contributions from health professionals, sociologists, academics, and – crucially – patients and their family members who had survived the critical care experience.

By the time someone is admitted to intensive care, one or more of their vital organ systems will be impaired or injured, their life will be in the balance. If they survive the experience, their bodies can take years to recover – the damage caused by muscle wastage, for instance, can last up to five years.

But as one of the contributors, Danny Kelly, reminded us, ‘We don’t just have bodies, we are bodies.’ A crisis for the body is a crisis for the mind and spirit too, especially when the person cannot comprehend what is happening, as is so often the case.

The accounts of former patients were riveting, particularly the details given by one young woman, who had been hospitalized for swine flu when she was 25, and quickly admitted to ICU, where she stayed for more than a month, her life in the balance. She brought a patient’s perspective to vivid life – the disorientation, the anxiety, the physical pain, the strange dreams and terrors that beset her – she spoke of dreaming that she had the feet of an elephant, then showed us a photograph of her in the ICU unit wearing huge blow-up sleeves on her lower legs which help with circulation and pressure sores. The mind make up its own reasoning when all around makes no sense.

The photographs that she had of her time in critical care, and scans of her first scrawled attempts at handwriting, seem to have helped her make sense of her experience, but she did not pretend that her recovery process was anything but gradual and prolonged. She had help from the Community Rehabilitation Service for six weeks, but said she was newly frightened of germs, and of coming into contact with the general public, and that the small amount of counselling she had received had helped her more than anything else. Even now, she said, two years on from her illness, things come back to her from that time.

It is estimated that around 25% of ICU patients will suffer from Post Traumatic Stress. One of the things that can help recovery is the construction and absorption of the ‘story’ – the exact sequence of events of a person’s illness, treatment and recovery, the separating out of what was imaginary and what really happened. It is standard practice in the modern army for injured soldiers to be accompanied by papers outlining the sequence of what happened to them – an understanding that psychologically we need not only to understand our story, but to be allowed to go over the details again and again, to embody that knowledge.

There is some interesting research work happening at the moment around the use of diaries and patient stories within ICU settings, and from the former patients at the Body in Crisis event, especially those most recently treated, I did get that sense of people going over the details again and again, just as one does in grief, to try to make sense of a new reality.

The ability of modern ICU units to snatch life back from the jaws of death is awe-inspiring, and to be celebrated, but for individual patients who have gone to that edge and back it is always a life changing event, a victory that is wrapped in calamity.

Plastic People

 I recently attended a lesson at the clinical skills centre at Little France  – I wanted to see students working with simulation models – dummies, in other words. The point of clinical skills is to get some hands-on experience in a scenario as similar to life as design ingenuity and latex technology can get you. And these days, that’s startlingly close.

The room was the size of a small ward, even had curtains and rails to divide the space into a three bedded unit. That’s not what you notice first, though, since you’ve just stepped into what looks like a charnel house. There are single arms everywhere, resting on bloodstained pads (as a dog owner, I recognise these as ‘puppy pads’ a central but largely useless part of canine toilet training – I’m glad they've found another purpose).  In the old days, apparently, you practiced your syringe skills on oranges. Now we have disconcertingly lifelike arms with veins you can inject into or draw from. The blood is a jollier, more fluorescent red than the real stuff. Each arm has a bag of it attached by tubing, giving the impression that someone has just stepped away from trying to revive it.

Around the edge of the room, a selection of anatomically detailed lower torsos sit on the countertop. I wipe the unbidden image of an Amsterdam sex shop window from my mind. The class I'm attending is a speedy overview of pregnancy and childbirth given by the cool-headed Carol Brown, who has brought many of these female parts with her, some in a box branded with the name of Adam, Rouilly, who specialise in such things. The box is printed with the jaunty strapline Limbs and Things. A lone male bottom is incongruously stranded amongst the female parts, very obviously waiting to have his prostate felt. Carol puts him aside.

She props up an entire pregnant female torso, and with a whisk of her wrist pulls down the outer skin to reveal an amazing sight: a full-term baby inside a see-through sac with placenta attached. There is pump to control the inflation level inside the sac, so that manual examination of the belly will be as near life as possible. Some speakers are fitted to reproduce foetal heartbeat sounds. It is both ingenious and oddly beautiful.

The first year students and I practice internal examinations, then deliver the model of a baby through a skeletal pelvis, then a fleshed-out dummy. Between tries, students absentmindedly cuddle or rock the plastic newborn. I even learn something about neonatal resuscitation. Although the lesson is intended as an overview, so persuaded am I by the experience of hands on dummy-nursing, I go away with a delusional idea that if someone went into labour in the aisle of Sainsburys, I might be of some help. A little learning, as they say.

Adam, Rouilly’s website is absolutely fascinating, with an overlay of weirdness for the casual visitor. The list of simulation models makes it clear that this kind of virtual practice concentrates on the more intrusive tasks – injections, intubation, catherisation, internal examinations, suctioning.  Ideally, nursing and medical students can use them to come to terms with the basic mechanics of the thing, so that, when it comes to dealing with living patients (I was going to say breathing patients, but some of these models do breathe) they can focus on the person as much as the task.

But – and it’s not a huge but, because I can see the good of all this. But. Look at the picture below.  As the mannequins become more sophisticated, could it be that healthcare professionals might start to compare us unfavourably with these plastic people – uncomplaining, unopinionated, can’t use the internet, don’t mind waiting for hours, extremely high pain threshold. The students have time to discuss things amongst themselves as these attractive ladies wait in wistful silence, putting the patient back into patients.

All photographs courtesy of Adam, Rouilly

Story workshops with nurses

If you scrutinise the photograph (left), you may notice that an essential part of running a writing workshop for nurses is baiting the trap with a selection of finger food. There is no better way to lure busy team members in the middle of their working day.

Along with Dr. Deborah Ritchie of Nursing Studies, I ran four lunchtime sessions for mental health nurses at the Royal Edinburgh Hospital, under the theme ‘Telling our Stories’. Our immediate aim was to generate fresh accounts of mental health nursing today. Not only for the pleasure and satisfaction of the exercise, but because the voices of nurses are so often missing in debates around healthcare. In the long term, we are interested in seeing how these kind of creatively generated stories could be used to inform research, planning and advocacy.

We were assisted by the wonderful arts organisation, Artlink, who run a range of creative activities for patients at the hospital. They kindly loaned the big kitchen at their Glasshouses base so that we could get away from the usual training room atmosphere and have a space that was more homey and informal.

A big thanks to all the nurses who took part, none of whom had done creative writing before, but who rose fearlessly to the challenge, producing work that was moving, funny, sometimes frightening and filled with a tough-hearted dedication.

The following was written by staff nurse Jo Dunlevie in response to a challenge to find metaphors or images that would capture the transition between work and home. It’s a fine piece of imaginative writing.

Work

Unfunny clowns in dangerous big shoes

Stomping animals growling in the dark

Bright lights, Loud horns

Blinking light to dark

High wire ooh's and Ahh's

A moment away from a fall

A Disaster, head off in the lions jaws

Home

Slow steady smiles

Big laughs and tiny giggles

Quiet steady light, and the smell of growing things

Friendly voice, nudging concern

Big sighs and lashes on sleeping cheeks

Soft fall of turning pages

And the Dum de dum of life in Ambridge

Good Nurse, Bad Nurse

Just to let you all know that I'll be giving a public talk at Edinburgh University on October 2nd. It's an occasion to mark the residency and to talk about the different and often distorted ways that nursing is reflected in our culture.

Here's the blurb:

‘Good Nurse, Bad Nurse’

Featuring a cast of drunkards ,saints, harridans, angels, sexpots, wimps  and mavericks, Nicola White, Leverhulme Writer in Residence at Nursing Studies Edinburgh, explores how nursing  has been portrayed in literature, film and popular culture and asks what part nurses play in their own stereotyping.

Hope that you get the chance to come along - it's free but ticketed and you can book HERE

Public talk, October 2^nd.  Doors open 6.30pm, talk starts 7.00pm, Teviot Lecture Theatre, Doorway 5, Medical School, Teviot Place, Edinburgh, EH8 9AG 

In the Surgeon's Hall

The Playfair Hall

After visiting the Anatomical Museum here at the Medical School, I went to see another important collection three minutes walk away. This is the Surgeons' Hall Museum. Before you reach the pathology specimens in the main hall, a classical, galleried space designed by William Playfair, you pass through displays devoted to the history of surgery, detailing the many advances made by surgeons in Scotland, such as Joseph Lister, who pioneered the first antiseptic, and James Simpson, who revolutionized surgery through his discover of the anaesthetic properties of chloroform. Obscure feelings of gratitude wash over me.

I‘m browsing the lit display cases when a handsome notebook catches my eye. Bound in what looks like rich brown leather, glossy, with elegant gold writing tooled into it. I lean in close and read, Burke’s skin pocket book– and have to take a step backwards, my covetousness turned sour.  Burke and Hare, the notorious 19^th century murderers are an integral part of the history of medicine in Edinburgh. And here is Burke’s death mask beside the little book. I have already seen his skeleton displayed in one of the glass cabinets at the Anatomical Museum in the university.

Burke's skeleton © Hugh Pastoll

William Hare is not here. Having testified against Burke, he was given his freedom. Knox, the surgeon who bought the bodies of those they murdered, is not here either. Burke was hanged and then publicly dissected, and souvenirs were made from some of his remains. The treatment of Burke’s body reflects the offense that his crimes caused to humanity, but more particularly the harm they caused the medical establishment. The continued display of his remains in these venerable institutions does have the air of an object lesson.

There are no women in evidence in the Surgeon’s Hall, other than as specimens. The portraits and photos are all of eminent men, men who pushed forward our knowledge and proffered solutions to much suffering. The process of healing and care of the sick, however, consists of more than technical solutions, and I find myself wondering how such an elusive, tender process could ever be captured in a display of objects and photographs. The world of care – the ordinary and transformative acts of bathing and nourishing and clothing – has no museum.

Although women are not commemorated in the Surgeons' Hall, the work of a woman has brought me here. The writer Kathleen Jamie wrote a magnificent essay on the Surgeons' Hall in her book Findings. It is the best thing I have read about places like these, places that call forth all kinds of competing emotions.

‘Dr. Barclay was a man who could take up a tiny scalpel and flay, most delicately, the corpse of a small child until nothing remained but arteries and veins running to and from their destinations. The result hangs here in a glass closet. Around a small skeleton the blood vessels swarm stiffly, and the skeleton is arranged with arms uplifted, as though at play. For a while, in this room of still and suspended things, we must suspend judgement.’ – from ‘Surgeons' Hall’ Kathleen Jamie © 2005

I urge you to read the full essay, it is a beautifully structured, thoughtful piece of writing and manages to find an equilibrium between the seeming cruelty of this slicing and probing and the motivation that spurs it.

Jamie quotes an 1863 book by the Edinburgh physician John Brown, entitled Rab and his Friends. The story features a rare early description of a surgical operation on a woman with breast cancer. The author asks the reader’s forgiveness for the young medical students who he describes jostling eagerly for places at this spectacle:

“Don’t think them heartless…they get over their professional horrors and into their proper work, and in them pity as an emotion ending in itself, or at least in tears and a long-drawn breath, lessens – while pity as a motive is quickened and gains power and purpose. It is well for poor human nature that it is so.”

In the Anatomical Museum



photo:Hugh Pastoll



Across the quadrangle from where I work is the most compelling collection, guarded by the skeletons of two long-dead elephants.

Edinburgh’s Anatomical Museum was once the centerpiece of the medical school, a galleried hall three stories high, housing a collection devoted to comparative anatomy - a kind of democracy of bones where human skeletons took their place alongside those of other animals. In a photograph taken in 1898, below, you see the museum in its heyday, a suspended procession of whales and other cetaceans floating over the earthbound beasts below.

In the 1950s the museum was reduced to a single floor, and many of the skeletons were moved out to the nearby Museum of Scotland. Some smaller animals remain, and a gorilla stands alone in one of the fine glass and rosewood cases. All the furniture and fittings are original, with the AM monogram on the backs of chairs, and although the museum has been brought up to date here and there, with bright plastic models of various body parts and their workings, it is the old things that attract me, the curling labels with hand-inked captions, the bell jars and specimen tanks, the detailed models made from wax or papier maché.

There are strange and beautiful things here; a resin casting of lungs that looks like a delicate bloom of coral, tiny bones laid out in patterns like beadwork on a framed black cloth, and a dissected corpse looking like something dug up from a peat bog, blooming here and there with tiny silver droplets. This is the emergence of the mercury which was injected into this body"s lymphatic system to trace its routes more than two hundred years ago. And even while I’m peering closely at these things, I feel a certain inhibition, because they are not just objects, they are parts of people, or in the case of the dissected man, nearly all of a person.

Medical and anatomical museums are discreet places, not often open to the public. Our bodies are usually disposed of with ceremony, buried or consumed by fire, but these remains remain because they are or were put to use – they are objects to think about and through. As the latin motto inscribed over many European mortuaries and dissection halls exhorts Mortui Vivos Docent. Let the dead teach the living.

And the living are here too – students softly tapping keyboards or reading in bays amongst the glass cases, using the facilities of the museum for their anatomy coursework, or perhaps just liking it as a place to study – the fine polished tables and skylights and special hush. A girl leafing through a folder flicks back her long hair in front of case containing preserved brains, hunkered in their individual tanks. It is odd that of all the intricate insides of the body, a brain looks the dumbest, a cross between cauliflower and clay.

The students have grown used to their surroundings, grown used, perhaps, to the idea that their lives will be concerned with the body in a way those outside the world of medicine and healthcare are not.

As I leave, I’m stopped in my tracks by two old framed notices to the left of the doorway. They are menus of a sort, lists of body parts.

Head and Neck, one side ............................14s

Head and Neck when opened, one sIde............ 10s 

Upper Extremity .....................................14s

Perineum and Pelvis, when opened,one side ...... 5s

and so on, piece by piece.

For lack of further explanation, I have to presume this is what students of another age paid for parts to dissect. It’s the baldness of it that makes me stop; something quite extraordinary made into notices that look like a price list from a shop. They’re not callous, they’re factual, but they remind me of all the sentiments a person might have to put aside to do this kind of learning.

The museum today

I’ll be writing another posting about the museum soon, but in meantime I want to mention that it’s open to the public one day a month and that the next opening is this Saturday, 26^th of May from 10:00 until 16:00 (Last entry:15:30). For further information, see the website.