Dr Tony McCluskey | Updates

Doctors, Nurses, Patients, Hearses

Dr Tony McCluskey — Thu, 13 Aug 2026 00:00:00 +0000

How can someone with a beating heart be dead?

A beating heart has been the prime indicator of the presence of life for thousands of years. A beating heart means life. Its absence means death. Modern medicine forces us to accept that this rule is both simplistic and wrong. A person can be dead while their heart continues to beat in their chest. On the other hand, a person can be very much alive even though their heart has stopped. A person can be alive even if they don’t currently have a heart. Like quantum physics, the modern medical concept of death is difficult to get your head around. But that’s not going to be a problem for you after you’ve read this post.

Death made simple

We all know what death is. Or at least we think we do. We don’t like saying the word out loud because it forces us to confront our own mortality. Notwithstanding our fears, death awaits us all, even if we often prefer to use Monty Pythonesque euphemisms for being dead when we absolutely must engage with the subject: stunned; deceased; pining for the fjords; demised; passed on; pushing up the daisies; history; kicked the bucket; shuffled off his mortal coil; run down the curtain; gone to meet his maker; joined the bleeding choir invisible; an ex-person; no more; ceased to be; expired; stiff; bereft of life; resting in peace.

One thing’s for sure: when you’re dead, you’re dead. End of. Except successful cardiopulmonary resuscitation, open-heart surgery, organ transplantation and the concept of brainstem death challenge our simple, intuitive, commonsense notion of what we think of as death.

If asked, most of us instinctively equate being alive with the presence of a heartbeat. Breathing is pretty important too, but the general consensus is that we will breathe until and unless our heart stops beating. For most people, the fact that an unresponsive person hasn’t breathed after a few minutes of careful observation is enough to convince them that person is indeed dead, regardless of whether they think they can feel a pulse or not. We don’t expect the being dead situation to change, either. People don’t spontaneously rise from the dead like a modern-day Lazarus. Death is a permanent state. Irreversible. There’s no going back from being dead.

Declaring somebody dead if their heart isn’t beating and they aren’t breathing works pretty well most of the time. Like Newtonian physics, it seems to describe the real world in which we live accurately. However, like Newtonian physics, our simplistic notions of death are wrong.

If you think about it, you already know that at least one of the attributes we associate with death is up for debate. That woman in the park last week, for instance, that you read about in the local paper, was undoubtedly dead when she was found deeply unconscious and unresponsive by a dog walker. She wasn’t breathing and had no pulse. The dog walker performed effective CPR, and when the paramedics arrived six minutes later, they diagnosed ventricular fibrillation and zapped the woman with their defibrillator. She woke up in hospital disorientated, agitated and confused, but these are behaviours associated with the undead, not the dead. We can reasonably conclude either that one of the fundamental tenets of death, of it being a permanent and irreversible state, is patently untrue, or that the woman was not dead in the first place.

Why a beating heart does not prove someone is necessarily alive

Most people, and I include doctors, even an intensivist such as me who diagnosed many patients as brainstem dead, find it challenging to get their heads around the idea that a person can be dead even though their heart is still beating. Rather like quantum theory, it doesn’t make intuitive sense. To get to grips with the concept, you need to do a bit of deep thinking.

Consider this. If you remove a healthy heart from a brainstem dead person’s body, provide it with oxygen and nutrients and it will continue beating for hours. Nobody would argue that the person the heart was removed from is still alive because their heart is beating. Nobody would argue that the beating heart is a person, either. A beating heart is evidence only that the heart, as an organ, is alive. Not the person. Transplant that same heart into another person and we do not transplant that heart’s owner into the recipient. The idea that the personality, the mind, the soul of the donor are transplanted along with their heart is patent nonsense.

Your heart is important.

As are your lungs.

Your kidneys are important, too.

But none of these organs is what makes you the person you are – a living, unique human being. That would be your brain. A heartbeat is evidence only that the heart is alive. It is not evidence that the person is alive.

What about someone who has been guillotined?

Was Marie Antoinette still alive and conscious, if only for a few seconds, immediately after her head was chopped off on the guillotine? Did she have time to think, ‘That didn’t hurt a bit,’ as her head rolled into the basket? Her heart would have continued to beat for several minutes afterwards. At what point did she die? I put it to you that most reasonable people would argue that Marie Antoinette ceased to exist as an independent, unique individual (died) pretty much straightaway because her brain, containing her essence, was permanently disconnected from its life support system when she was beheaded. What her heart might have been doing for the next few minutes would have been irrelevant.

Why not having a beating heart doesn’t mean that a person is necessarily dead

During open-heart surgery, cardiac surgeons intentionally stop the patient’s heart. A beating, mobile heart interferes with the delicate surgery they need to perform to bypass obstructed coronary arteries or to replace defective heart valves. A heart-lung bypass machine temporarily performs the functions of both the heart and the lungs during the several hours it takes for surgery to be undertaken. The patient does not have a beating heart. Nor are they breathing. The patient is unquestionably alive, though. No one would regard them as dead. The reason they are deemed to still be alive is that their brain, the repository of that person’s mind, personality, spirit, and soul, is alive. It just so happens that the person isn’t breathing and their heart has stopped for a while.

To take our thinking one step further, a patient who undergoes heart transplant surgery does not even have a heart during the period between their original, defective heart being removed and their new, transplanted heart being plumbed in. So now we can state that you can still be alive and not have a heart at all, whether it be beating or not.

A thought experiment

Would you be alive or dead if only your brain existed as a going concern, suspended in a vat of nutrient broth? You would have the capacity for thought and self-awareness. You might also be able to smell and see, although, being disconnected from a peripheral nervous system, you would be unable to taste, hear or touch your world. My question isn’t whether such a life would be worth living. It’s whether this state would constitute being alive. And before you answer no, how does this condition equate to being dead, the only other alternative?

It’s the brain, stupid

Whether we are alive or dead depends on what our brain is doing, or is capable of doing.

Arguing the toss about what Marie Antoinette might or might not have been thinking immediately after her head separated from the rest of her body might be fun for the university debating society, but declaring a person to be dead even though their heart is still beating is not an academic question. Without the concept of brainstem death, countless patients with no hope whatsoever of ever waking up again would be kept ‘alive’ on a ventilator to no purpose. Their loved ones would be given false hope, their agony of suffering needlessly prolonged. It would also mean denying the precious resource of an ICU bed to someone else with a realistic prospect of recovery from their critical illness. And without brainstem death, countless people with intractable heart failure, severe lung disease, kidney failure and liver failure would be denied the opportunity of receiving donated organs and instead be condemned to lives of misery and suffering before their premature deaths.

The brainstem versus the brain

Our brain is a relatively large organ occupying the entirety of the inside of our skulls. It weighs about three pounds (1.4 Kg) and receives fully 20% of the total cardiac output pumped through the circulation by the heart, regardless of how brainy or stupid we are, or whether we’re concentrating fiercely on some problem or other versus daydreaming about spending the day with Kylie Minogue (other fantasy idols are available). Our consciousness resides within our brain. Our personality. Our sense of who we are. The very essence of who we are.

The brainstem is a projection from the base of the brain comprising the midbrain, pons and medulla oblongata, that acts as a neural control centre, regulating all manner of vital functions. It’s relatively tiny, weighing in at only an ounce (25-30g). For such a small amount of tissue, it’s incredible what the brainstem does. To have any chance of understanding why we are dead if our brainstem is dead, we need to have some knowledge of what functions our brainstem performs.

The next four paragraphs are for the nerds among you and contain a somewhat detailed description of what your brainstem does, day in, day out. For those of you with a less than nerdy disposition, feel free to jump ahead. You won’t miss anything essential.

What has my brainstem ever done for me?

The brainstem serves as the neural connection between higher cerebral centres (cerebral cortex, thalamus, hypothalamus, amygdala and hippocampus), where we think, feel, emote, remember things, and so on, and the spinal cord below. Apart from this key role as a neural relay station, the brainstem also contains numerous neurophysiological control centres.

The brainstem regulates and controls the heart and circulatory system. Hunger, thirst, the body’s temperature control thermostat, and a myriad other control centres are all here, too. Although all these different regulatory and control centres within the brainstem are vital for life, two particular areas are of paramount importance: the Reticular Activating System (RAS) and the respiratory centre.

The RAS, a dense network of nerve cells located within the brainstem, is responsible for determining whether we are awake, conscious and self-aware on the one hand, or asleep and unconscious on the other. It determines whether we are connected to the real world or disconnected from it. The RAS isn’t itself the seat of consciousness. Rather, it is a switch that tells higher cerebral centres to wake up when it is set to the ‘On’ position. If the RAS fails, rather like a traditional petrol-engined car without a starter motor, the brain is going nowhere.

The other neural centre within the brainstem of supreme importance is the respiratory centre. Breathing is regulated by collections of neurones that function as an automatic pacemaker without which we would all stop breathing and die as soon as we fell asleep. If the respiratory centre is damaged beyond repair, an individual can never breathe for themselves.

Most of the cranial nerves arise from the brainstem, the exceptions being the olfactory nerves (sensitive to smell) and the optic nerves (sensitive to light), which can almost be viewed as outward projections of the brain. As we shall learn in a later post, testing the function of these brainstem cranial nerves, as well as testing whether an individual in apparent deep, unresponsive coma can breathe for themselves, forms the basis of making the diagnosis of brainstem death.

As a related aside, sufferers of a rare medical condition called Ondine’s curse have a malfunctioning respiratory pacemaker. Individuals affected have no automatic drive to breathe. Not a problem while they’re awake. They can simply remind themselves to keep breathing. The situation becomes slightly trickier when they fall asleep, though. Voluntary control of breathing is lost, and there is no autopilot to take over. Such individuals simply stop breathing. Sufferers of Ondine’s curse generally require a permanent tracheostomy and mechanical ventilation while they sleep.

This final bonus paragraph is for the űber-Nerds only. Ondine was a mythological water spirit in European folklore. These elemental spirits could only gain a human soul by marrying a mortal man. Ondine married a knight named Lawrence. When she discovered he had been unfaithful, she cursed him so that he must forever will himself to breathe. If he ever fell asleep, he would die. For days Lawrence fought a gruelling battle to stay awake. Eventually, sheer exhaustion overcame him, he fell asleep and died. Lawrence was a dead man walking, perhaps the first documented case of someone with a beating heart being dead already.

Ah! The non-nerds have rejoined us. Welcome back.

The brainstem contains our drive to breathe. It coordinates essential reflexes. It integrates the body’s responses into a single functioning whole. Although the brainstem is not the seat of consciousness, it contains the switch to turn our consciousness on and off. The loss of brainstem function means the switch is permanently set to the off position and therefore the capacity for consciousness is lost.

To reiterate: when a person’s brainstem is damaged beyond repair, there is zero possibility of that individual ever regaining consciousness. They will never breathe for themselves. They will never again be the person they once were. Which is why, in the UK and other countries throughout the world, the death of a person can be diagnosed if there is irreversible loss of brainstem function, regardless of what their heart might be doing.

Brainstem death takes our understanding of death to a whole new level, though. Its diagnosis is not a prediction that someone will die soon. It is not a statement that recovery is incredibly unlikely. Neither is it a description of a deep, unresponsive coma that a person might possibly wake up from one day, however unlikely. It means the person is dead. Even though their heart may continue beating. Even though a mechanical ventilator may push air in and out of their lungs.

What causes brainstem death?

You already knew (or thought you knew) before reading this post that a person dies when their heart stops beating – well, it is true at least 99.9% of the time. Or when they stop breathing – also true 99.9% of the time. Everybody knows that. It’s commonsense and accords well with how we observe the world operating around us. Hopefully, you now appreciate that the reason why someone dies when they stop breathing, and their heart stops beating, is because the death of the brain as a whole, including the all-important brainstem, inevitably follows after a period of only a few minutes without it receiving its regular oxygen and nutrient supply. But perhaps you’re still sitting on the fence about this brainstem death lark. You want to know more. In particular, you want to know what might cause someone’s brainstem to peg it when their heart is quite happy to bat on.

The demographics of brainstem death are different from regular cardiopulmonary deaths. The victim is more often relatively young and fit before disaster strikes out of the blue. A massive subarachnoid brain haemorrhage resulting from a ruptured cerebral artery aneurysm, for instance, causes a massive rush of blood into the closed confines of the rigid, bony skull. Intracranial pressure spikes precipitously, cutting off the blood supply to the brain and causing further injury from oxygen starvation. The brainstem is forced downward through the opening at the base of the skull where the brainstem joins with the spinal cord, crushing all the vital neural control centres housed within it.

Other major insults to the brain cause a similar outcome – a severe head injury, meningitis and encephalitis, lack of oxygen to the brain (in contrast to a lack of oxygen to the body as a whole) caused by strangulation or beheading.

Although the brainstem may die first, the rest of the brain soon follows suit from the adverse effects of elevated intracranial pressure. If you performed an EEG on such a person, it would show a flatline. Zero electrical activity within the brain. A sort of cerebral asystole. The concept that you may be dead if your brain is dead is less difficult to accept if you have ever attended a post-mortem examination where the deceased was diagnosed brainstem dead and watched as the pathologist literally poured the liquefied, necrotic brain out of the top of the skull into a metal dish. This liquefaction occurred before the victim’s heart stopped beating, not after the fact.

The doctors only say you’re brain dead so that they can nab your organs!

The inevitable question arising when we pronounce a person with a beating heart, mechanically ventilated lungs and functioning liver and kidneys dead is how we can be sure they won’t recover. Absolutely, 100% sure, that there isn’t even a one in a million chance they might recover. Even if recovery only meant existing in a minimally-responsive coma for the rest of their life, it would prove that a person diagnosed as brainstem dead hadn’t ever been dead in the first place.

It’s also important to state that the ICU medical team looking after a potential organ donor and the surgical organ transplant team are strictly separate. There is no direct conflict of interest.

What happens if you don’t turn off the ventilator after brainstem death has occurred?

The most important thing is what doesn’t happen. There has never been a single documented case of an adult fulfilling the necessary preconditions for assessment and satisfying all of the criteria for brainstem death subsequently regaining consciousness. It really is an everyone dies scenario.

I can already hear the shouts of protest from the back: But only last week I read in the paper/saw in my social media feed/heard on the radio/ watched on the TV news that someone diagnosed as brain dead miraculously woke up.

These are sensationalised media headlines representing irresponsible reporting. In every single case that has been properly investigated, the reality was that the patient was never actually brain dead in the first place.

This is what always happens if you keep a brainstem dead patient on a mechanical ventilator and continue to actively manage them:

1. Their blood pressure progressively drops despite heavy doses of powerful stimulants.

2. Their heart fails.

3. Their body temperature drops as physiological systems wind down.

4. Their hormones stop being secreted.

5. Their brain rots.

Even with aggressive medical intervention, the body of a brainstem dead individual cannot be sustained. Over a period ranging from a few days to a few weeks, the various bodily functions deteriorate and break down, regardless of how many drugs, fluids and artificial hormones are administered. Cardiac asystole inevitably supervenes.

Conclusion

There are two definitions of death. One definition, the commonsense notion, is that you die when there is an irreversible cessation of your circulation. Your heart has thrown in the towel, and nothing is going to make it start up again. You stop breathing as a result. The second definition, which you may have considered for the first time while reading this post, is that you also die when there is an irreversible cessation of your brainstem function following catastrophic damage to it.

Thinking about it, if your heart isn’t beating and you’re not breathing, catastrophic, irreversible damage to your brainstem follows naturally. It is this that makes you dead, not the absence of a beating heart per se.

A final word

Phew! That was hard going. The gluttons for punishment among you will be wondering why I haven’t said anything about clinical brainstem death tests and organ donation. Worry not. I haven’t forgotten. Both subjects will be coming up in a future post.

Check out my website at https://www.drtonymccluskey.com for more details about my books and how you can read free chapters.

My three books, Vocation, Resuscitation, and Resignation, are available to purchase as eBooks or paperbacks at https://www.amazon.com/dp/B0DJ3273KH.

(https://www.amazon.co.uk/dp/B0DJ3273KH for readers in the UK).

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Doctors, Nurses, Patients, Hearses

Dr Tony McCluskey — Sat, 1 Aug 2026 00:00:00 +0000

Medical terminology

Two of the commonest complaints about doctors are that they write in an indecipherable scrawl and they don’t speak plain English. You emerge from an appointment with your GP or hospital consultant, clutching a clinical case summary that seems to have been written by randomly inserting incomprehensible ancient Greek and Latin words throughout the text (I’m assuming here that it was a printed document and not handwritten, in which case you wouldn’t have been able to read it at all). I’m not going to cover doctors’ handwriting in this post. My own is a perfectly legible, calligraphical script that is a veritable ocular pleasure to read. We’ll stick to language.

There are so many Greek and Latin words in medical jargon, which we shall call ‘Medicalese’, that medical students could be forgiven for thinking they’d mistakenly enrolled on a classical history degree course during their first few weeks of study. Patients could be forgiven for thinking that medical jargon exists solely to keep them in the dark. That isn’t the case – most of the time. When doctors use jargon, they are usually talking to each other rather than trying to mystify everyone else. However, confusion and worry may result if jargon is used thoughtlessly when talking to patients and their relatives.

So why do doctors converse in another language? Why don’t they simply use plain English all of the time and be done with it? It’s probably true that doctors could and should use plain English more often. Patients deserve explanations they can understand. However, technical language has its advantages, and all professions speak their own lingo. Law. Teaching. Engineering. Science. Flying an aircraft. Medicine is no exception. Medicalese exists because it is succinct, precise and unambiguous. One doctor can communicate with another, knowing they will be perfectly understood and avoid any confusion. This may not be the case when talking in plain English. A long-winded explanation of exactly what message you are trying to convey may then become necessary.

For example, one doctor speaking to another on the phone about your heart condition might say you have atrial fibrillation while turning to you and explaining that your heart rhythm is irregular. Both are true descriptions. However, the plain English version is imprecise and could be interpreted in several ways by another doctor. It does have the virtue of being easily understood by a patient, but a further explanation would be required if the patient wanted a more complete understanding of their condition.

Medicalese and plain English both have their place. Good doctors are fluent in both languages and can easily flip between the two as suits their audience.

So far, so reasonable, but I can tell that you’re still wondering why so much Medicalese is Greek or Latin – or even both at the same time. This isn’t quite as weird as it sounds, though. For example, the word television derives from the Greek word tele, meaning distant, and the Latin verb videre, meaning to look at. To understand why doctors persist in conversing in Latin and Greek, we need to know a tiny bit of history.

Medicine has been around for almost as long as mankind has. If you had travelled to ancient Greece around 400 BC, you might have sought medical advice from Hippocrates himself. Many of the earliest scientific discoveries, including the study of medicine, were written in Greek. Centuries later, the physician Galen expanded the body of medical knowledge, also writing in Greek. And everyone has heard of such titans of ancient Greece as Pythagorus, Aristotle and Archimedes. All of their published experimental findings and scientific theories were recorded for posterity in Greek. So were the concepts and terms they defined, as well as the organs and diseases they named.

Then the Romans pitched up, and Latin became the principal language of medieval European academia and scholarship until the 19th Century. Universities taught in Latin long after it became extinct as a spoken language. Medical textbooks were written in Latin. Prescriptions were written in Latin. Anatomists labelled every part of the human body in Latin. Diseases were given Latin names.

The end result of this mishmash was that, over hundreds of years, doctors inherited both Latin and Greek as the two base languages used to describe the principles and practice of medicine. It developed in an organic, haphazard way such that a given organ or disease might have a name derived from Latin, Greek, or both. Sorry, but that’s the way it is. Don’t blame me. Blame Hippocrates. Him and his bleeding oath – which I never took, by the way. It wasn’t the done thing when I studied at Manchester Medical School. If you’ve ever read it, you’ll probably agree that it’s a load of old tosh. For example, the Hippocratic oath bans the use of surgery!

As well as numerous words taken from ancient foreign languages, the world of medicine is full of specialist terminology, contractions, abbreviations and TLAs (Three-Letter Acronyms). Long ago, when I was nervously awaiting my A Level examination results to see if I’d made it into medical school, I read an article in the local paper that said medical students have to learn more than 20,000 new words before becoming doctors. Phew! That’s as many words as the average native English speaker uses.

Even if the reason why doctors speak Greco-Latin gobbledegook today isn’t primarily to make them appear clever and superior, Medicalese sometimes does have that effect. Let me give you an example. You have gone to see your GP because you have noticed your muscles are always sore and aching, and you don’t know what’s causing your symptoms. Your GP takes a full medical history from you, gives you a thorough physical examination, and takes a blood sample to send to the lab for a battery of tests.

You see your GP again two weeks later, and he informs you that you are suffering from something called idiopathic fibromyalgia. The treatment is to take daily exercise, as well as paracetamol on days when the pain is at its worst. Unfortunately, the condition can’t be cured, and you are just going to have to live with it.

You leave the surgery disappointed that there is no curative treatment for your debilitating condition but relieved that you’re not going mad and it’s not all in your head. You have a genuine medical condition. Even the name is quite impressive. Idiopathic fibromyalgia. Marvellous. You have a diagnosis that will impress your friends and ensure that your employer cannot possibly object the next time you have to take time off work to recuperate.

You, your friends and your employer might not be quite so impressed if they knew that idiopathic (Greek idios = peculiar, pathos = disease) fibromyalgia (Latin fibra = fibre; Greek myo = muscle, algia = pain) simply means you are suffering from generalised muscular aches and pains, and that your doctor hasn’t the foggiest idea what’s causing them, nor what to do about them. In other words, your GP knows no more about what ails you than you did before you saw him. He’s just given your symptoms a fancy name.

Here’s a short list of some other complicated diagnoses made simple:

Onychochryptosis – ingrowing toenail.

Synchronous diaphragmatic flutter – hiccups.

Borborygmi – stomach rumbling.

Eructation – burp.

Hyperhidrosis – you sweat profusely, even when it’s -10ºC outside.

Sphenopalatine ganglioneuralgia – brain freeze.

Vasovagal syncope – a simple faint.

Cephalalgia – simple headache.

Hippopotomonstrosesquipedaliophobia – the fear of long words.

The arbitrary, haphazard use of both Latin and Greek is sometimes confusing even to doctors, particularly when both languages are used to describe different aspects of the same organ, tissue or medical condition. A few further examples give the general idea.

When talking about the womb, doctors refer to the uterus (Latin). But when they talk about the surgical removal of the womb, they use the term hysterectomy (Greek). And the doctors who deal most with the womb are specialists in Obstetrics (Latin) and Gynaecology (Greek).

Kidney stones (renal calculi – Latin) are surgically removed by urologists (Greek) during an operation called a nephrectomy (Greek).

Dermatologists are skin specialists (dermis and epidermis – Greek) who treat cutaneous (Latin) diseases.

Many Medicalese words are Greco-Latin hybrids, like television. For example, hypertension (Greek high, Latin pressure), hypotension (Greek low, Latin pressure), cardiovascular (Greek heart, Latin vessel), gastrointestinal (Greek stomach, Latin bowel), claustrophobia (Latin enclosed space, Greek fear). The list goes on and on.

As well as purloining fancy Latin and Greek words that nobody who didn’t benefit from a classical education can understand (and yes, I do realise that I have used a fancy English word myself that nobody but a nerd like me would understand without a dictionary), doctors love using medical abbreviations, contractions and acronyms. The much beloved TLA (three-letter acronym), of course, takes pride of place in the lexicon of any self-respecting doctor.

A typical conversation between two cardiologists:

‘I wonder if you would see Mr Smith and tell me what you think.’

‘Delighted, old chap. What’s the story?’

‘It’s rather sad, really. He’s been a CHD patient of mine in the OPD for many years. He has a few other things wrong with him – CKD, recurrent UTIs, COPD, NIDDM, several TIAs. Anyway, he was admitted to the CCU two weeks ago with an MI and acute LVF. He had an ICA, and we found that his LAD was obstructed. A TOE showed AS and MR. He underwent PCI to treat his CAD. Then a day later he had a DVT, which precipitated a PE, confirmed on V/Q scan. Then his LFTs and U+Es went off. His USS was normal, and we presumed he’d developed ARF secondary to ATN. He was improving until yesterday when it all went pear-shaped with PAF. That caused him to have a CVA followed by a VF cardiac arrest. We achieved ROSC, but I’m not too sure that did him any favours. Now he’s in the ICU. They think he’s BSD and TLC is all we can do for him. He’s not for CPR, naturally. I really would value your opinion.’

If you know what all those abbreviations mean, you know.

You’ll find older hospital notes littered with all manner of more dubious acronyms and choice phrases, their meanings clear to doctors the world over but indecipherable to the uninitiated. Let’s say they are not entirely politically correct, and no doctor would dare use such terminology these days. However, I often came across them in patients’ medical notes when I first started out. Indeed, I confess to adding the occasional barbed comment myself. While not in any way condoning the ritual abuse of patients, and apologising profusely right now for any transgressions on my part, the practice reflected an entirely different culture during an era when patients didn’t have an automatic right to see what was written about them in their medical notes and doctors, perhaps, were too free in their use of what we might call NHS frontline gallows humour to de-stress after a challenging consultation. Recording this type of entry in a patient’s notes would now be regarded as unprofessional, even offensive. We didn’t think so at the time, although we do now. So with all that in mind…

(Please skip this next section if you are easily offended.)

Crumble – an old person with severe frailty and multiple comorbidities.

Dross – a patient who doesn’t really need to be in hospital because they have a condition that is chronic and untreatable. They are more of a social problem than a medical one. GPs would often refer dross for hospital admission on Friday afternoons so that their golfing weekend wouldn’t be disturbed. That was in the days when GPs actually worked at weekends.

NFB – normal for Buxton (the final letter may be substituted depending on locale). In other words, the patient is as thick as a plank (with sincere apologies to all Buxtonians).

GOK – God only knows. The diagnosis when you haven’t a clue what’s wrong with someone.

TTFO – told to fuck off. Although not usually literally. The patient is a time-waster with nothing much wrong with them, and you’ve discharged them from further follow-up.

Acopia – there’s nothing at all wrong with the patient. They just have an innate inability to cope with the normal stresses and strains of life.

FLK – funny looking kid. Refers to a child presenting with dysmorphic features, especially physiognomic (affecting the head and face), which lead the doctor to suspect an underlying but as yet unidentified chromosomal or other genetic abnormality. FLKs are often seen in conjunction with FLPs – funny looking parents. In fact, while FLK isn’t at all acceptable in this day and age, it was a genuinely useful clinical term back in the day, encapsulating and communicating a clinical dilemma succinctly and precisely.

O sign, Q sign and Dotted Q sign. These three terms represent a continuum of the increasing cerebral impairment often observed following a stroke. The O sign is when the patient’s (usually edentulous) mouth is stuck open in the shape of an O. The Q sign is said to be present when the patient’s tongue pokes downwards from the corner of an O sign mouth. The dotted Q sign is when a fly settles on the tongue and may be reversible (tongue capable of moving) or irreversible.

That’s it for this post. Hopefully you’ve taken it in the spirit I intended. I always had the utmost respect for all my patients, treating them with dignity at all times.

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Doctors, Nurses, Patients, Hearses

Dr Tony McCluskey — Wed, 22 Jul 2026 00:00:00 +0000

The anatomy of a hospital (Part 2)

Mortuary

Every doctor is used to seeing dead bodies on a regular basis. As one of the group of ICU consultants, I was a particularly frequent visitor to the hospital mortuary. However, I saw my first dead body at the very beginning of my training on day one of week one in the Dissecting Room (DR) at medical school. Actually, I saw twenty dead bodies that day, one for each tutorial group, all lined up in neat rows lying on top of metal trolleys. It was the start of the process of desensitisation to death that all doctors undergo, sad but necessary if they are to continue functioning while their patients are dying like flies around them.

As soon as medical students qualify, they encounter more dead bodies on the wards. Lots of them. Only these bodies have blood rather than formaldehyde in their arteries and veins. It’s usually the house officer’s job to certify hospital patients dead. They also attend them during cardiopulmonary resuscitation while the jury is still out, deliberating on whether a patient is alive or dead. I’m not sure how many dead bodies I saw in total during the course of my medical career, but it certainly ran into hundreds.

Although death and dying are familiar to hospital doctors, seeing a dead body in the mortuary somehow takes things up to a new level of sadness, added to which there is a sense of the macabre. Mortuaries are obviously not everyone’s cup of tea, and I include most doctors. Nevertheless, I always found that the people working in the hospital mortuary, who were on intimate terms with the refrigerated corpses that temporarily resided there, were among the cheeriest people you could ever wish to meet. I suspect a cheery disposition is an absolute prerequisite for working as a mortuary technician or a pathologist. That, and an underdeveloped, preferably genetically absent, sense of smell.

Unless you are a histopathologist performing post-mortem examinations (aka PMs or autopsies), the commonest reason for most doctors to have to visit the mortuary is to confirm that a person really is dead before attesting to that fact on their cremation form. I always found it an unpleasant duty, although the bitter pill was sweetened by the cheque that arrived from the funeral director in due course for signing the authority to cremate the deceased’s body (Ash Cash). It was obscenely good money for ten minutes’ work, too. The geriatric house officer could earn a fortune during their six months in post, and the rest of us envied them.

Dead bodies undergo major physical change in the short interval between dying on the ward and being viewed in the mortuary, a mere 24-48 hours later. A metamorphosis, you might even say. On the ward, dead patients look exactly the same as they did when they were still alive, only a tad less lively. I would have no trouble recognising them. If it weren’t for the fact that they weren’t breathing, they might just have been enjoying an afternoon nap. The recently deceased often looked better dead than they had when their bodies had been fighting desperately to stay alive. However, whenever I went to view an ex-patient in the mortuary, and the technician opened the metal door of their refrigerator, one of many in a large bank making up the back wall of the mortuary, and slid my patient out on their cold, hard, metal bed, they were often unrecognisable. Not in a hideous way. It’s just that they did not have the appearance they’d had in life. Not inhuman, exactly, but lacking the essence of humanity. Corpses in the mortuary had more in common with the wax figures in Madame Tussaud’s than with real people. Their spirits, their souls, the very cores of their being, had well and truly left the building. The only way I could ever be sure that somebody really was the patient I’d come to see was to check their identity wristband.

For the ten years I trained as a junior doctor and during my earlier years as a consultant after that, I often popped down to the mortuary to attend the PM of a recently deceased patient. There were two types of PMs back in the day: coroner’s PMs and hospital PMs. The former were statutory and ordered by HM Coroner if he or she deemed one necessary to establish the cause of death. Consent from the patient’s family was not necessary. Relatives of the deceased could object. However, permission from the next of kin to undertake the other type, a hospital PM, was mandatory. We, the doctors, requested one whenever we thought that examining the internal organs of a loved one might be educational and improve the medical management of similar patients in the future. Although there were occasional refusals by next of kin to consent, the prevailing attitude at the time was to grant the request.

Societal attitudes have changed dramatically in the intervening period following various scandals involving human organs and tissues. Doctors became reluctant to ask for consent for a hospital PM, and relatives were unlikely to agree if asked. Thus, every PM examination performed on one of my ex-patients during the second half of my consultant career was a statutory one ordered by the coroner.

Another seismic shift regarding PMs was introduced around the same time. Our area coroner forbade members of the clinical team who had been looking after a deceased patient to attend their PM. He was concerned that we might alter our witness statements based on the findings at PM. I stopped attending PMs altogether. Good news, perhaps – after all, who really wants to go to a PM if they don’t have to? On the other hand, in my view, it was a shortsighted approach and a great shame. Attending a PM wasn’t the most pleasant duty of a hospital doctor, but it was instructive to correlate the stages of a patient’s final illness with the observed organ damage.

The Hospital Staff Dining Room

(more latterly known simply as The Hospital Dining Room)

The hospital staff dining room, as its name suggests, was once the preserve of hospital staff – doctors, nurses, physios, porters, domestics, even managers. There were also exclusive doctors’ dining rooms at the beginning of my medical career. When I was a medical house officer at Manchester Royal Infirmary, all the juniors would dine together at the end of the day in our exclusive enclave in the doctors’ mess, where we would be served a three-course meal. Sadly (for us), doctors’ dining rooms came to be considered an anachronistic privilege for a profession no longer quite so hallowed. They disappeared. Quite right, too, I hear you cry. Elitism, favouritism and non-inclusivity. I wouldn’t necessarily disagree, although it was most enjoyable while it lasted. Plus, a lot of useful work got done while we were chomping through our steak and kidney puddings, chips, peas and gravy. Difficult cases were discussed at dining table seminars, with different opinions offered on the differential diagnosis and which investigations to order next. A request from the cardiology SHO for the endocrinology SHO to see their patient with heart failure whose blood sugars were high would be reciprocated by a request from the endocrinology SHO for the cardiology SHO to see their diabetic patient who had an undiagnosed heart murmur. Dinner wasn’t just an entertainment, it was an education.

While the loss of doctors-only dining rooms is one thing, the loss of the hospital staff dining room and its replacement with a restaurant open to the general public is quite another. The hospital managers, in their great wisdom, saw a money-making opportunity and decided to open up the catering facilities to all-comers – mobile patients escaping the ward in the search for better food, followed by a post-prandial smoke afterwards; relatives; random members of the public out for a meal, treating the place like a local bistro; the odd feral dog or cat. The hospital dining room was no longer a haven for stressed-out, tired-out doctors and nurses to chill out for half an hour over a hot meal. It no longer afforded the opportunity to moan and complain; to de-stress by enjoying the gallows humour of the NHS frontline; to discuss a tricky case and ask for advice. Now the world and his wife might be sitting at the next table, or even at the same table, earwigging your conversation.

You might find yourself eating lunch, having just come from a difficult conversation on the ward with the family of a critically ill loved one, only to become uncomfortably aware of them sitting at the table to your right. Or worse, you might be unaware they are sitting behind you while you regale your dining companions about said patient’s non-existent chances of survival and that it would be better for all concerned if you could put them out of their misery by shooting them because you wouldn’t treat a dog like that. Or the person sitting beside you, polishing off a double-sized portion of apple crumble and custard, might be the diabetic patient whose high blood sugar you struggled to understand why it was not under control when you saw them in the outpatient clinic earlier.

Apart from never being able to escape pesky patients and their relatives when you’re supposed to be on your break, there were other problems. Sometimes you couldn’t even get into the hospital dining room because it was jam-packed with interlopers. The minute hand on your watch would move quicker than the mile-long queue to be served. By the time you did make it to the serving area, they would have run out of the braised steak and roast potatoes, the fish and chips, and the lamb madras curry with pilau rice. All that would be left would be dried-out baked potatoes with a less-than-interesting mashed potato filling. Not that it would matter because you’d be due back in theatre or on the ward by now and wouldn’t have time to eat it.

Although the hospital staff deliver a 24/7 service every single day of the year (managers excepted, of course), the hospital dining room isn’t open 24/7 to serve hot food. It used to be when I first started out. Extended opening hours were a lifesaver at three in the morning, when you’d been running around all day like a blue-arsed fly, seeing patient after patient, with never a chance to sit down for even five minutes for a bite to eat.

But that was before the bean counters got involved for a second time. Having opened the hospital dining room to anyone who fancied eating there, they now restricted the opening hours to coincide with maximum footfall. The shutters went down at six o’clock, and anyone trying to sustain themselves through a night shift or 24 hours on call had either to bring in their own butties or take their chances on whatever offerings were available in the chilled vending machine.

Typically, you would be tempted by cheese and tomato pizza (plastic cheese, tasteless tomatoes, rubbery base), baked potato and more plastic cheese, a cheese and tomato sandwich (same as the pizza, but with white, sliced bread) or spaghetti bolognese (any Italian nurses unlucky enough to give this dish a try would be on the next plane back to Bologna). A far tastier and infinitely more nutritious alternative, if you didn’t have a Pot Noodle to hand, was to go back to the doctors’ mess, where there were loaves of sliced white bread, mountains of butter and a toaster. Thickly buttered toast was the fuel that kept acute medical services running during the night and saved many a life. All NHS toasters should be awarded an OBE.

The WRVS shop

An alternative to the hospital dining room was the WRVS shop (Women’s Royal Voluntary Service, rebadged as the more inclusive RVS since 2013). There was one in every hospital I trained in back in the day. Although their opening hours were often more limited than even the hospital dining room, the WRVS shop was an alternative outlet for obtaining something to eat and drink. This could be useful in a fluid balance or blood sugar emergency, but was otherwise best avoided for several reasons.

Firstly, the WRVS shop specialised in trademark sandwiches. Whether they were boiled, flavourless ham on white, the mildest of mild cheddar cheese on white, sulphurous egg mayo on white or their signature fishy-but-not-from-the-sea tuna mayo on white, the flour their bakers used to make the bread was sawdust. The only thing you could truly taste was the one-inch-thick coating of axle-grease flavoured margarine on the slices of bread.

Secondly, it always took forever to reach the front of the queue. When you were finally served, it took even longer to close the deal on your choice of lunch. Let’s say you’d foolishly ordered a cheese sandwich and a coffee. Gladys would put the kettle on, take two slices of bread and spread them with margarine. Then, she’d search here, there and everywhere for the cheese. ‘Dot, where’s the cheddar?’ Dot, who would be round the back stocktaking or hard-boiling eggs to make egg mayonnaise, would pipe up, ‘At the back of the fridge, bottom shelf.’ Gladys would spend forever looking up and down the fridge for the cheese until suddenly remembering it was still on the counter where she’d left it after making a previous cheese sandwich. At long last, your sandwich would be ready for you. Now to pour the boiling water onto the instant coffee, only to discover the wall switch to which the electric lead of the kettle was connected was in the off position.

Three minutes later, you would be handed your sandwich and coffee. But that had been the easy bit. Now it was time to tot up the bill. The combined mathematical talents of Gladys and Dot would be needed for this task, along with several sheets of paper and a pencil. A blunt one, which first needed sharpening. Figures would be jotted down and calculations made. ‘That will be £35.10, please. No, that can’t be right.’ The previous calculations would be scrubbed out with Dot castigating Gladys for making a schoolgirl error in her adding up. Something to do with the decimal point being in the wrong place. ‘That will be twenty pence, please. No, that can’t be right.’

‘It’s £2.76,’ you offer, trying to be helpful. Gladys and Dot smile at you with a knowing look which proclaims, ‘Why don’t you leave this to the professionals?’

Just when you’re considering doing a runner, assessing (correctly) that neither Gladys nor Dot is up for the chase, Gladys announces, ‘It’s £2.76, please.’ You attempt to pay up, but sadly, you only have a £5 note and the change has to be calculated. Several pages of calculus and quadratic equations are required, only to discover that the till is empty of change. The starving hungry people in the queue behind you, which by now stretches out of the shop and halfway down the long main hospital corridor, have a whip-round to pay for your lunch. You thank them all profusely before suddenly remembering your patient who’s been admitted with a massive heart attack. Ah well, they can hang on a while longer while you have your lunch, can’t they?

Hospital Car Parks

Aka the chief exec’s cash cow

Don’t get me started on hospital car parks. There is no topic more likely to transform normally docile, amenable hospital workers into frenzied maniacs on the rampage, incandescent with rage and baying for the blood of the first hospital manager they clap their eyes on. Okay, I will tell you about hospital car parks but only as a fairy tale so I don’t become apoplectic while writing it all down and have a heart attack or a stroke on account of my blood pressure being somewhere north of 200/150.

Once upon a time, there was a district general hospital in a town on the edge of the countryside. It was a happy hospital, and everyone loved working there. The main hospital buildings were centrally located on an enormous campus, surrounded by acres of green fields and car parks. There was so much space, in fact, that the car parks were never more than half full, even on the busiest of busy days. Parking your car was free, whether you were a member of staff, a patient, or a visitor. Nobody would have dreamed of making the heroic hospital staff pay to come to work, not even the big, bad chief exec who ran the hospital.

Until one day, the big bad chief exec had a brainwave and decided to build an enormous new pharmacy on one of the fields. Two years later, another field was concreted over to make way for an education centre. A year after that, another field disappeared, replaced by a new day case unit. Before long, the hospital was all out of fields, and when the patients, visitors and hospital staff looked out of the windows, everything was dull and grey. It made them feel sad.

The big bad chief exec was far from finished, however, and it became his mission to put a new building on every scrap of land the hospital owned. A new theatre block, a new critical care unit, a new ED, a new paediatric block, a new maternity block, a new management block, and so the list went on. The doctors’ mess was bulldozed to make way for a new surgical assessment unit.

By now, almost all the hospital car parks had been built over, and the poor hospital workers were finding it difficult to park when they came to work. The big bad chief exec noticed what was happening and came up with a solution. He would charge patients, visitors and staff to park. That would force many of them to make other arrangements to get to work, such as public transport, cycling, and walking. Pressure on the car parks would reduce, and his staff would become fitter and healthier into the bargain, needing less time off work due to illness. Yes, it was a good, green solution. As a bonus, his new scheme would generate additional revenue.

The hospital staff didn’t quite see it that way. Lots of them worked shifts and were coming into work before the buses started running or leaving after they’d stopped. Most of them lived too far away to cycle or walk to work and, anyway, you would be taking your life in your hands riding along the A6 during rush hour. Fights would often break out as a consultant surgeon argued the toss with a nurse from the ED over who’d seen the only available space first. Everyone became even sadder.

As more new buildings went up and more and more car parking real estate was lost, the big bad chief exec had to come up with wilder schemes. The car parking charges went up and up, year on year. He said the money was needed to maintain the car parks and pay for the security staff to hand out penalty car parking charges to anyone breaking the ever more complex car parking rules. He was lying, of course, and eventually admitted that the profits were siphoned off to plug the ever-increasing black hole in the hospital’s balance sheet.

Eventually, even the big, bad chief exec recognised that charging a hospital porter or a student nurse nearly a day’s pay to come into work each week was a bit much. He came up with a new brainwave to solve all his problems. He would introduce differential pricing. Student nurses and porters would pay less because they would be subsidised by the fat-cat medical consultants, who could afford to pay more. A lot more. That was only fair, surely. He had high hopes that if his new scheme was successful, he would introduce differential pricing in the hospital dining room. Fish and chips, that will be £2.50, Mr Hospital Porter. Fish and chips, that will be £10.50, Mr Consultant Surgeon.

But the charges were still too costly for most people, and hospital staff voted with their feet. Everybody handed back their car parking permits and parked in neighbouring streets, on grass verges and in children’s play areas instead. The big bad chief exec wasn’t best pleased. He had to deal with hordes of angry local residents, and the hospital was losing money. It was a lose-lose situation.

Then along came the COVID pandemic. That was very sad indeed because rather a lot of people died. NHS workers were suddenly elevated to the status of national heroes, and the health secretary, in his immense gratitude, abolished car parking charges for hospital staff – and everyone else. Hurray! And all the car park users lived happily ever after. Well, for two years, actually, until car parking charges were reintroduced.

The VIP Visit Storage Room

Aka The room of requirement

I never discovered the whereabouts of one of these in any of the hospitals I worked in because their precise location within a hospital is always a closely guarded secret. However, I am reliably informed they do exist. The room of requirement is always well stocked with all the necessary paraphernalia to ensure that any VIP visit to the hospital goes swimmingly. There are shelves stacked up to the ceiling with pots of paint in every shade, rolls of silver ribbon, gold scissors, plaques, fresh flowers (replaced daily), garden planters and red carpets. There are also banks of syringes pre-loaded with sedative drugs to inject into the doctors and nurses who will form part of the reception committee to ensure they behave in a calm, docile and dignified manner. Slagging off the local MP on live TV, whose only interest in visiting the hospital is the photo-opportunity it affords, is verboten. So is any criticism of the chief exec.

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Doctors, Nurses, Patients, Hearses

Dr Tony McCluskey — Wed, 8 Jul 2026 00:00:00 +0000

The anatomy of a hospital (Part 1)

When we think of a hospital, most of us picture a general ward or perhaps the operating theatre. The reality is that there are dozens of different locations within a typical District General Hospital (DGH), some more important than others, that are necessary for high-quality patient care. There are even more specialist areas in major teaching hospitals (regional tertiary referral centres), such as cardiac surgery units, neurosurgical units, major trauma centres, organ transplant units, etc. (In case you were wondering about primary and secondary care units, these are your local general practice and your local DGH respectively.) The following is far from a comprehensive take on how I think key areas of a hospital function.

The Doctors’ Mess

I’ve put the doctors’ mess at the top of my list because it’s the most important part of any hospital. The nerve centre. Mission Control. Or at least it used to be.

Back in the olden days (well, the 1980s do feel like ancient history) when I was a medical student and then a junior hospital doctor, the doctors’ mess really was something. Most newly-qualified house officers and SHOs were single. They lived in the mess, which was usually a substantial building situated in the centre of the hospital campus or part of the main hospital building. The mess comprised living quarters, a kitchen and dining room, a bar, a TV and games room, and often a hall where the legendary doctors’ parties were held. Some messes, like the one at Manchester Royal Infirmary, served freshly cooked food to the junior doctors at mealtimes.

The doctors’ mess was not simply a place for juniors to eat and relax during periods of relative quiet; it was also a place to confer informally with colleagues from different specialities about tricky patients. More of this kind of referral work was accomplished in the doctors’ mess than by going through official channels and filling out lengthy patient referral forms. The doctors’ mess method was much more efficient, too. A busy surgical SHO at the end of yet another long and stressful day would be more far more likely to make the effort to squeeze in a visit to assess a patient with abdominal pain on the chest ward as a favour to a mate he’d been playing pool with the night before than if an impersonal referral form from a doctor he didn’t know had suddenly appeared in his pigeonhole asking him for his opinion.

Of an evening, the mess would often be quite busy with off-duty juniors lounging around, watching TV, supping pints from the bar, and playing pool. If you were on call, it was great to nip down to the mess, if you could manage to break off from saving lives for half an hour, for a chat and to grab something to eat (the staff dining room would now be closed, of course). Even better if the mess was in one of the few remaining enlightened hospitals that didn’t know the cost of everything and the value of nothing, and so still delivered trays full of sandwiches and snacks to the mess every evening to keep the hungry troops’ morale and blood sugar up.

Although my memory must be at fault here, I recall that there was a doctors’ party in the mess most weekends. What riotous occasions they were. The main guests, apart from the junior doctors, were nurses, of course. A motley collection of porters, radiographers and physios would also pitch up to join in the fun, as well as coachloads of people nobody had ever clapped eyes on before. Nobody seemed to mind. The music was loud, the dancing was hot, the booze seemingly never-ending, and the bedrooms above were conveniently available for any party-goers who overdid things and got over-tired. Or whatever.

We did well to party as hard as we did because doctors’ messes, as they existed then, were on their way out. Hospital chief execs, in their droves, decided they needed the buildings for a higher purpose: to house themselves and their managerial underlings. Or the building needed to be demolished to make way for a car park. Doctors’ messes nowadays have been relegated to small, out-of-the-way cubby holes and cupboards under the stairs.

It makes me sad to think about the demise of the doctors’ mess. We juniors had a place to de-stress, socialise, make friends, relax, and party. Yes, we worked a ridiculous number of hours and were sometimes on continuous duty for 48, even 72, hours at a time, but the doctors’ mess provided sanctuary, friendship, solace and support during difficult times. In conjunction with The Firm system, the mess played an essential role in maintaining junior doctors’ mental health. Both the mess and The Firm are long gone, and as far as I can see, nothing satisfactory has replaced them.

Hospital HQ

Hospital HQ is usually located at the hospital’s epicentre, where the doctors’ mess used to be until it was annexed by the chief exec. It’s the place where the executive team and other senior hospital managers work. Hospital HQ is the only carpeted area of a hospital with nice decor. Apparently, a hub of intense cerebral activity during regular working hours, the lights were all switched off by the time I was leaving for home after another hard day in the operating theatre. And the place was entirely abandoned at weekends and during bank holidays.

The Emergency Department (ED)

Aka Accident and Emergency

Aka Casualty

Aka Drop-In Centre for the homeless, the clueless, drunks, down-and-outs, wasters and time-wasters, the bad, the mad and the sad, and anyone else with nothing better to do and nowhere else to go who decide to pop down to their local ED to ask about the headache they’ve had since last Christmas and tonight seems as good a time as any to get it sorted given that there’s sod all on TV.

The ED is the hospital’s front door, and it’s always open. All are welcome. Nobody is ever turned away. This is in sharp contrast to the back door of the hospital, the way through to hospital discharge, which is permanently blocked by legions of frail, elderly patients whose needs are now social or nursing rather than medical but have nowhere else to go because of the dearth of investment in social care and nursing homes over past decades.

Most EDs are like a war zone or a scene from a disaster movie with bodies, dead and alive, lying everywhere – in cubicles, on trolleys, on the floor, in corridors, in cupboards. There are too few doctors and nurses running feverishly hither and thither from one victim to the next, desperately trying to do their best for as many patients as possible. Hopefully, nobody will slip through the cracks on this shift.

As a patient, you are supposed to be triaged (graded as to whether your condition is immediately life-threatening, serious but can wait an hour or two, walking wounded, or trivial), diagnosed and treated, and either discharged home or admitted to the hospital, all within 4 hours. When I was a consultant, I could have counted the number of occasions when the 95% target was met on the fingers of one hand. I remember we generally achieved somewhere between 85% and 95%. Little did we know at the time how stormingly marvellous we were performing. Currently, only about two-thirds of patients meet the 4-hour target, with 10% waiting more than 12 hours. And 3% of elderly, frail, seriously ill patients are waiting longer than 24 hours!

Having entered through the front door and having finally been seen by a doctor (unless you’ve died in the interim or pissed off home because you think you’ll receive better care there), you exit the ED in one of the following ways:

1. You are kicked back out of the front door with the admonition to consult your GP the next time your piles are itching again.

2. It’s a bit more serious, and you are taken to the mortuary.

3. You are transferred directly to the ICU, put on a mechanical ventilator and have tubes, catheters and drains shoved up every natural orifice, as well as a few man-made ones.

4. You are admitted to the Coronary Care Unit because you’re having a heart attack.

5. You are rushed up to the operating theatre for emergency surgery to have a buzzing foreign body removed from your rectum.

6. You are admitted to the Medical or Surgical Assessment Unit for further treatment and stabilisation of your presenting acute illness before being transferred to a hospital ward a day or two later.

The Intensive Care Unit (ICU)

Aka Critical Care Unit; not the same as the High Dependency Unit (HDU).

The ICU is where you’ll normally find the sickest patients in the hospital – at least those with a realistic chance of surviving. One of the main differences between the ICU and the HDU is that most ICU patients depend on mechanical ventilators to breathe for them, whereas HDU patients can manage on their own. The ICU patients are also more seriously ill, as a rule, having a greater number and severity of organ system failures. For these reasons, the nurse-to-patient ratio in the ICU is generally 1-to-1, whereas on the HDU it is usually 1-to-2. We used to say that you were buggered if you ended up on HDU, but if you needed to go to ICU, you were well and truly fucked. We might have been exaggerating, though, because more than 75% of patients admitted to the ICU survive to hospital discharge. I’ll have more to say about what goes on in the ICU and HDU in a later post.

Acute medical and surgical wards

This is where hospital inpatients spend most of their time. Characterised by too few nurses looking after too many patients, it’s surprising that there is no clearly defined recommended minimum standard for safe staffing on acute medical and surgical wards, even though there is evidence that a nurse-to-patient ratio in excess of 1-to-8 is associated with an increased risk of patient harm. Hellishly busy and noisy during the day, pandemonium breaks out as soon as it gets dark, when all the patients who have been in hospital for more than a few days go bonkers. Those that are physically capable run, naked, up and down the ward all night, screaming like banshees, usually trailing their urinary catheter bags behind them, while being chased by a harassed junior doctor with a big syringe full of Valium or some other powerful sedative. Their less physically adept ward companions join in by wailing and howling and falling out of their beds to break their hips. Before the long night is over, the frazzled nurses join in the lupine chorus.

All of this means that when you are admitted to a ward with a nasty bout of double pneumonia, you’ll inevitably suffer from acute sleep deprivation into the bargain, which is not conducive to getting better because it depresses your immune system, stresses you out and finally turns you into a raving lunatic after sunset so that the whole vicious circle is maintained.

Your only chance is to somehow blag yourself a cosy side room, a refuge from the madhouse, where you can hunker down and concentrate on getting better. It’s easier said than done, though, because there is a dearth of side rooms in most NHS hospitals. Patients only enjoy the amenity of the extra privacy and en suite facilities that a side-room affords for one of four reasons:

1. You’re a private NHS patient (oxymoron alert) and have paid for the privilege.

2. You receive special treatment because you are a VIP, such as the Duke of Kent, a member of staff, or a relative/personal friend of the consultant.

3. You’ve got a horribly contagious, deadly, infectious disease.

4. You’re on your way out, but nobody’s told you (by far the most common reason).

If you aren’t a VIP and you’ve got money to burn, try for 1. Otherwise, 3 is worth a go. You could probably simulate bubonic plague with a red marker pen. Most doctors and nurses are rubbish at diagnosing rashes, so they would probably keep you in the side room just to be on the safe side. If none of the above applies to you and you’ve been given a side room anyway, you might want to consider making those finishing touches to your last will and testament before anything else happens.

Delivery Suite (DS) and the Special Care Baby Unit (SCBU)

These are both very scary places, although for different reasons.

The DS is inhabited by two of the most intimidating groups of people I worked with as an anaesthetist – midwives and labouring women. I only ever went there if it was absolutely necessary. The SCBU is even more terrifying with its tiny little scraps of humanity weighing less than a bag of sugar lying helplessly in their incubators, being mechanically ventilated and fed via nasogastric tubes. Far too small for me. How the neonatologists (paediatricians specialising in the care of neonates, that is, newborn babies in their first month or so of life) managed to cannulate veins I would have needed an electron microscope just to see, I will never know. Thank goodness, I was seldom called down to the SCBU in an emergency.

Operating Theatres

Most people have a pretty good idea about what goes on in theatre, and they are wrong. The bit they get right is that there’s a patient asleep under anaesthetic (usually) being operated on. The surgeon beavers away, his sweaty brow being delicately mopped periodically by one of the theatre nurses. There is dead silence for long periods of time to allow the surgeon to concentrate. Conversation, when permitted, is erudite and professional, relating to how surgery is progressing or perhaps debating the relative merits of a new procedure. Apart from the surgeon, also present in theatre are a scrub nurse, who passes the surgeon instruments, and a circulating nurse (the one who’s always depicted in TV medical dramas picking up used, bloody swabs with a pair of long forceps and hanging them on a metal stand). Last and certainly least, there is an anaesthetist. They don’t usually feature in the action very much, but the TV producer knows they’re there doing something. Together, they make a tight-knit team. Everyone is naturally in awe of the surgeon, including the surgeon, who is definitely in charge. The team is 100% focused on the patient at all times, their every thought and action devoted to saving yet another life.

It might be like that on TV and even in a few real-life operating theatres, but I never worked in one. The first difference between imagination and reality is just how many personnel are routinely required to properly look after a patient going under the knife: the lead surgeon; one, sometimes two, surgical assistants; the scrub nurse; one or two circulating nurses; a consultant anaesthetist and a trainee anaesthetist; an anaesthetic assistant (either an anaesthetic nurse or an Operating Department Practitioner); a theatre orderly (gofer), sometimes two; a radiographer, if X-rays are required during surgery. And that’s before accounting for any medical students, nursing students or paramedics observing proceedings, as well as random people from other theatres sticking their noses in to see what’s going on in between cases. I’ve been to less crowded football grounds than many operating theatres. But then, it’s not called theatre for nothing.

The second thing is that most operating theatres are far from quiet places. Music is usually playing from an ancient, bashed-up radio, at a volume ranging from soft background to an eardrum-rupturing 100 decibels, in genres as diverse as classical, easy-listening, pop, heavy rock, grunge and garage (I’ve no idea what the last two are). For some reason that nobody can explain, the radio’s aerial is always broken or missing entirely, and has been replaced by a pair of Spencer Wells forceps clipped to the aerial base. It’s amazing what sterling reception you get with a pair of Spencer Wells. As well as the melodic strains, there are usually several threads of conversation going on simultaneously, and none of them has anything to do with the patient or their operation. Like any other workplace, you are much more likely to hear about who’s rumoured to be shagging who, whatever was on TV last night, how ugly the patient is and what a wanker the new CEO has turned out to be.

I was an anaesthetist for over 30 years, so I feel reasonably well qualified to tell you what anaesthetists generally get up to while their patients are anaesthetised in theatre. First of all, rest assured that we do stay with you throughout your operation. If we didn’t, you would probably die. Or suffer a catastrophic brain injury from acute oxygen starvation and not wake up at the end of your operation. Or wake up paralysed and in agony during your operation.

When you’re under a general anaesthetic, you are not asleep. You are lying unconscious, eyes closed and unmoving, but the resemblance to natural sleep is superficial. The state of anaesthesia is one of deep, unresponsive coma, in which your brain function is suppressed to a level similar to that associated with brain death. When you are anaesthetised, your life hangs in a delicate balance between this world and the next. Your brain is incapable of carrying out its job of regulating all your vital functions, such as breathing, heartbeat, blood pressure, blood flow, fluid balance, kidney function, blood sugar, core temperature, and many more essential aspects of your body’s physiological control mechanisms.

Which is why your anaesthetist is ever present, watching over you like your guardian angel, keeping you safe. And they do all this while simultaneously completing today’s Telegraph crossword, studying this month’s British Journal of Anaesthesia or Hello! magazine, re-tuning the radio to another station at the surgeon’s request or reattaching the Spencer Wells forceps because it’s pinged off again, answering the theatre phone because nobody else can be arsed, adjusting the operating lights so that the surgeon can see what it they’re cutting out, and eating their lunch in the anaesthetic room because they didn’t have time to eat it at lunchtime – keeping a beady eye on proceedings through the window of the anaesthetic room door between mouthfuls.

You still need to be continuously monitored even if you aren’t under a general anaesthetic. For example, the blood pressure of patients having a hip replacement under a spinal anaesthetic has a dangerous habit of unpredictably disappearing into their boots if nobody is looking. To be honest, it’s harder work for anaesthetists to look after awake patients than it is for them to look after the ones who are asleep.

Doh! Even I’ve fallen into the trap. They’re not asleep; they’re anaesthetised.

If you’re awake, you need talking to – for reassurance, to relieve the tedium and just to be sociable. Plus, if you’re awake, everyone in theatre has to be on their best behaviour and try to act professionally, which is a real ball ache. No slagging off the CEO, for instance. Or you, the patient. And definitely no laughing at the surgeon when he cuts the wrong bit off and blood spurts everywhere. For these reasons, I usually convinced my patients having hip and knee replacements under spinal anaesthesia that they would be much better off being sedated while their new hip or knee was fitted. To be fair, they didn’t usually need much persuasion.

Day Case Unit (DCU)

When I first started out, if you were going to have your hernia (rupture) repaired or your gallbladder taken out, you would be admitted to the hospital at least one day before surgery, have your operation, and be discharged home a few days later. The whole episode could easily last a week or more. Nowadays, you pitch up on the day of surgery itself and have your operation before your husband or wife or whoever it was that brought you to the hospital has even managed to get out of the car park because their car was clamped in the ten minutes it took them to accompany you to the door of the DCU. You are discharged home later that same day. A different person has to come and pick you up because the first person’s car is still clamped.

Not having to stay in hospital for even one night, let alone a week or more, is great news. That’s something we can all agree on. Perhaps. Although if you happen to wake up at three in the morning in agony because the nerve block the anaesthetist gave you has worn off and the strongest painkiller you’ve been supplied with is paracetamol, you might beg to differ. All of a sudden, staying in hospital overnight and having a double dose of morphine doesn’t seem such a bad thing, after all.

The Outpatient Clinic

This is where your GP refers you when your case isn’t an emergency, but they want the advice of a consultant regarding your further clinical management, such as the need for surgery. The waiting areas in outpatient clinics are always jam-packed with desperate, seething masses of humanity, waiting hours on end for their chance to see the great man or woman. It would help if they were not all given the same 09:00 appointment time. Nobody knows why all the appointment times are the same. They just are. Always have been and always will be. I used to find that the situation was usually worse in the medical clinics than in the surgical clinics. Most surgical outpatients attend only two or three times: once before their operation and once or twice afterwards for their routine postoperative review. This is not the case with medical outpatients.

I found out at first hand why this is so at my very first medical outpatient clinic as an SHO working for a chest physician. I read the voluminous notes of the first patient before calling her into the consulting room. The last entry, dated six months previously, had nothing to do with her chest or breathing. Then, she’d been complaining of headaches, a nervous tic affecting her right eye, a painful big toe on her left foot and an itchy rash in her nether regions. Interesting stuff, perhaps, but not remotely respiratory.

I flicked back a page and read the entry from a year ago, thinking that must be when she had been complaining about her chest. However, there was no mention of her breathing except to note it was ‘the same as usual’ and to ‘continue taking her inhalers as prescribed’. There was mention, however, of her sore left elbow, abdominal gripes and flatulence, dizzy spells and a smelly discharge from her nether regions. Presumably, these symptoms from a year ago had all cleared up at her last clinic visit six months earlier, given that they hadn’t been mentioned then.

As I flicked further back through her notes, it transpired that Ethel had been on a six-monthly outpatient review for the past 15 years. Her GP had referred her originally because he had wanted some advice about how best to treat Ethel’s asthma. As far as I could make out, Ethel’s asthma had come under control almost immediately with a change of treatment and she’d not had any trouble with it for years. For some reason, she had never been discharged back to the care of her GP and so had been on six-monthly hospital follow-up ever since. Every time Ethel attended the clinic, she had a fresh constellation of symptoms that were always unrelated to each other. They often led to yet more blood tests and other investigations. These were always normal, and no firm diagnosis was ever made, but it didn’t really matter because all her symptoms would resolve between clinic appointments, to be replaced by a different set.

After hearing at length that Ethel’s latest complaints were a ringing noise in her ears whenever the weather was cold (wear ear muffs), a stabbing pain in her hip if she went dancing (try swimming) and was feeling tired all the time (TATT syndrome is nothing to worry about, we’ve all got it), I decided to take the bull by the horns and discharge her from further follow up. Ethel immediately burst into tears and accused me of being a heartless beast. Apparently, she didn’t get out much and looked forward to her clinic visits. Handing her a tissue, I relented and said we’d see her again in six months.

Nowadays, you’d probably be shot at dawn if you adopted that attitude. For years, hospital managers berated consultants for not discharging more of their outpatients. They tried unsuccessfully to change consultants’ mindset, proposing radical solutions to the problem of crowded outpatient clinics, such as telephone consultations. The consultants were having none of it. It was a dangerous proposition. Your patient needed to be physically present. Subtle abnormalities would be missed with catastrophic consequences. It took the COVID-19 pandemic to effect substantial change. Now you’re more likely to see tumbleweed blowing through the outpatient clinic than a crowd of patients.

The X-Ray Department

Aka Radiology, Diagnostic Imaging

It’s bloody marvellous what goes on in an X-Ray department these days. You can have a good old-fashioned plain X-Ray of your chest, broken arm or arthritic hip, of course. But there’s a whole bunch of other diagnostic investigations you can have, such as ultrasound scans, Computed Tomography (CT) scans, Magnetic Resonance (MR) scans, Positron Emission Tomography (PET) scans (who would have thought antimatter would be useful in diagnostic imaging), radio-isotope scans and fluoroscopic imaging (using continuous pulsed X-Ray beams to produce a real-time moving video) that allows your doctor or nurse to obereve organs and tissues actively functioning, for example, coronary angiography. But X-Ray departments aren’t only places to visit to be diagnosed with something because you are just as likely to be definitively treated for whatever’s wrong with you.

It’s called interventional radiology, a relatively new medical speciality that involves minimally invasive therapeutic procedures performed by inserting needles, catheters, wires, and fibreoptic endoscopes through minor skin incisions or existing bodily orifices under image guidance (X-rays, ultrasound, CT, MR, fluoroscopy, etc.). The medical consultants who do this stuff are radiologists (as opposed to radiographers, who are highly qualified medical technicians and not doctors).

Their menu of procedures is extensive and includes:

1. Removing gallstones causing a blockage and/or infection in the bile duct.

2. Inserting stents in the bile duct to bypass an obstruction, eg a tumour.

3. Inserting stents in the oesophagus (gullet) to provide symptomatic relief to patients with advanced oesophageal cancer.

4. Insertion of stents into narrowed arteries, such as coronary, carotid, and lower limb arteries. Alternatively, a catheter with a balloon at its tip may be passed down the narrowed artery to the constricted area. When the balloon is inflated, it stretches the narrowed vessel open, after which the balloon is deflated and the catheter removed (balloon angioplasty).

5. Percutaneous nephrostomy, a bypass procedure that involves passing a drainage catheter through the skin into the collecting system of a kidney whose outflow tract is blocked by a tumour or stone, thereby allowing it to drain freely. It’s a relatively straightforward procedure to preserve kidney function that previously would have necessitated a major open surgical procedure.

6. Embolisation, a procedure in which either a metal coil or gel foam is positioned within an artery to block the onward flow of blood. There are a variety of applications, such as preventing subarachnoid brain haemorrhage in patients with leaky cerebral aneurysms and cutting off the blood supply to malignant tumours.

7. Endovascular Aneurysm Repair (EVAR) in which a stent-graft is inserted into a large Abdominal Aortic Aneurysm (AAA) to prevent catastrophic fatal haemorrhage.

The huge advantage of interventional radiology is the avoidance of the otherwise necessary conventional major surgery, which means it requires a shorter hospital length of stay, is less expensive and is less of an ordeal for the patient. Crucially, interventional radiology is inherently safer and has a lower mortality than conventional surgery, meaning it can be offered to patients where surgery would be contraindicated because of the high risk of death.

That’s all for now on the anatomy of a hospital. We’ll continue this thread in the next post.

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Doctors, Nurses, Patients, Hearses

Dr Tony McCluskey — Thu, 25 Jun 2026 00:00:00 +0000

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)

Death cannot be prevented. It can only ever be postponed.

Often, not for very long.

The Last Act, Death Scene: Take 1

You and the rest of your family are at Granny’s house, gathered around her bed. She’s dying. At ninety-two, she’s had a good innings. She’s ready to go. Her health has been declining for several years, which has been hard for Granny and you all because she was always so active. It’s her failing heart. She gets breathless on minimal exertion these days and has become housebound. She can’t manage her stairs and sleeps on a sofa bed in the lounge. Granny’s family doctor, who has known her for over thirty years, informed her several days ago that there’s nothing much he can do. Granny has accepted her fate.

‘I’m not going into hospital when the time comes,’ Granny announced to all of you a few months ago. I want to die in my own bed, in the house where I’ve lived these past fifty-odd years, with my family around me.’

That time is now. Granny has pneumonia. She’s gasping for breath. The family doctor calls and concurs with Granny that her treatment should not be escalated. She won’t be admitted to hospital. He will prescribe her sedative medication to keep her comfortable. He signs a community DNACPR form. You all agree it’s for the best.

Granny has a nice cup of tea, gives you all a kiss and quietly goes to sleep. All is calm. All is peaceful. All is quiet reflection and love. Granny doesn’t wake up.

The Last Act, Death Scene: Take 2

You and the rest of your family are in the Medical Admissions Unit of the local hospital, gathered around Granny’s hospital bed. She’s dying. At ninety-two, she’s had a good innings. Her health has been declining for several years, which has been hard for Granny and you all because she was always so active. It’s her failing heart. She gets breathless on minimal exertion these days and has become housebound. She can’t manage her stairs and sleeps on a sofa bed in the lounge. Although Granny knows deep down that her time may be short, she finds it hard to accept. She hasn’t discussed her situation with anyone. It would be too upsetting all round.

When Granny goes down with pneumonia, a doctor who does not know Granny prescribes her antibiotics. Her condition worsens. By Saturday, she is gasping for breath and can hardly speak. Granny is taken to hospital. After a battery of blood tests, a chest X-ray and a CT scan, the diagnosis of pneumonia is confirmed. Granny receives intravenous fluids and more antibiotics. She becomes confused and doesn’t recognise any of her visitors, including you. The consultant looking after Granny asks to speak to you all. She tells you all that Granny is seriously ill and might not recover. She might die, in fact. The news comes as complete shock. Granny’s consultant, who is clearly a very experienced doctor, convinces you all that attempts to resuscitate Granny, should her heart stop, would be futile. Accordingly, she signs a DNACPR form.

Granny remains in a critical condition, alternately unconscious and agitatedly confused. She’s stopped eating and drinking. During her brief lucid intervals she tells you and anyone else who will listen that she wants to go home. You know Granny is suffering and that this isn’t what she would want. Granny languishes in hospital and dies a week later. The end is mercifully peaceful, though. You and her entire loving family are by her side as Granny slips quietly away.

The Last Act, Death Scene: Take 3

You and the rest of your family are in the Medical Admissions Unit of the local hospital, gathered around Granny’s hospital bed. She’s dying. At ninety-two, she’s had a good innings, though. Her health has been declining for several years, which has been hard for Granny and you all because she was always so active. It’s her failing heart. She gets breathless on minimal exertion these days and has become housebound. She can’t manage her stairs and sleeps on a sofa bed in the lounge. Although Granny knows deep down that her time may be short, she finds it hard to accept. She hasn’t discussed her situation with anyone. It would be too upsetting all round.

The house officer tells you that Granny is very ill but that she’s in the right place and they’re doing everything they can to treat her. Granny remains in a critical condition, alternately unconscious and agitatedly confused. She’s stopped eating and drinking. During her brief lucid intervals she tells you and anyone else who will listen that she wants to go home.

You are with Granny a few days later. The rest of the family will be along later. Granny’s been asleep the whole time you’ve been visiting, her breathing irregular and raspy. She becomes suddenly silent. Her chest is not moving. You stare at her for a few seconds. The terrible truth strikes you like a bolt of lightning. Screaming at the top of your voice, you race down to the nursing station. ‘Granny’s not breathing! Granny’s not breathing!’

Pandemonium erupts. Three nurses race towards Granny’s bed, one of them pushing the resuscitation trolley and defibrillator. A squad of doctors charge down the ward soon afterwards. Horrified, you stare spellbound as Granny’s nightie is torn away to reveal her shrunken, naked breasts. One of the nurses starts performing external chest compressions. You hear the snap as at least one of her ribs breaks under the strain. One of the doctors attaches the defibrillator gel pads while another sucks out vomit from the back of Granny’s throat. The sight is overwhelmingly sickening, but you cannot tear your eyes away. One of the nurses tries to guide you away, but you’re not budging. You can’t move. You are almost literally petrified.

The scene is noisy. It’s chaotic. It’s frightening. It’s traumatising for you, and for Granny. It’s undignified. It’s the opposite of the calm, peaceful, painless way to go that you imagine a good death to be. More to the point, it’s pointless, you realise.

Fifteen minutes later it’s all over. Granny is still dead.

I’ve described those three takes to set the scene for the rest of this post. Before continuing, I suggest you spend a few minutes in reflection mode. Which of those scenes would make the director’s cut from Granny’s perspective? From your perspective? What are the important factors that influence which of the takes plays out in real life?

Of course, I’ve omitted Take 4 in which Granny gets better and goes home again. This is highly improbable given the context I described, although not impossible. How does this possible outcome, however unlikely, colour your judgement of how best to approach Granny’s clinical management?

Real Life versus TV Medical Dramas

Why don’t hospitals resuscitate everyone who has a cardiac arrest? There’s surely nothing to lose. Nobody should be written off. It’s a human right.

These are all reasonable points. If you’ve watched enough medical dramas, you’ll know exactly how cardiac arrest works. A patient suddenly collapses. Alarms start ringing. Ruggedly handsome doctors and pretty nurses (stereotypically male and female, respectively) sprint down the ward. Someone shouts, “Clear!” A defibrillator is fired. The patient jolts dramatically into the air as a thousand volts or more of electricity course through their chest, and coughs once or twice. The ECG trace, which had hitherto been flatlining, springs back to life with a reassuring ‘beep, beep’ sound. By the next episode, the patient is back at work regaling their colleagues about their near-death experience.

On the television, CPR either works, with a very good chance of the patient bouncing back to a normal life, or it doesn’t. There’s hardly ever any vomit, blood or shit about the place. No broken ribs. No shouting and certainly nothing chaotic. The whole performance is expertly choreographed. Poetry in motion. Real life is somewhat less cinematic with an outcome that is a whole lot less positive. And it’s far, far messier.

Although people feel familiar with cardiac arrest resuscitation, CPR is one of the most misunderstood areas of modern medicine. DNACPR orders are even more misunderstood and often provoke strong reactions. They touch on something people find uncomfortable and don’t like to think about. None of us is immortal. We are all going to die. Despite all its remarkable advances, modern medicine cannot prevent this.

It’s a grim reality, but refusing to acknowledge and accept that simple truth hampers good decision-making around ensuring that somebody’s death, if it cannot be prevented, is as good, as peaceful and as dignified as it can be. That’s good decision-making by doctors but also, crucially, by patients and their families, too.

Success rates for CPR

The return of spontaneous circulation (ROSC, or, to put it simply, the patient’s heart starts beating again) is clearly the goal of CPR. However, the success rate varies enormously depending on why the heart stopped in the first place, where cardiac arrest occurs, how quickly resuscitation begins, the patient’s age and underlying health, and a dozen other factors. There is a key difference between a person dying because their heart has suddenly thrown a wobbler, on the one hand, and a person’s heart throwing in the towel because that person is dying, on the other. For some patients, CPR offers a genuine chance of survival with a good outcome. For others, it offers virtually none. And an outcome worse than death is always on the cards.

As we saw in a previous post, CPR is a violent physical assault on a person. It’s messy. It’s more than distressing to witness as a loved one. It’s often distressing as a healthcare provider, too. And it’s a million miles away from the quiet, peaceful, dignified death that finally comes to us in our own bed at home that we all envisage, if we are forced to contemplate our own mortality. CPR is certainly not a medical intervention that should ever be undertaken lightly.

To determine which patients would benefit from a DNACPR order rather than from the performance of CPR on their dead bodies, we need to think about the different types of people who have a cardiac arrest (we could also say the different types of people who die), why they have had their cardiac arrest (why they have died) and what are the possible outcomes of CPR (there are more than two).

Who is more likely to benefit from CPR?

· An otherwise reasonably healthy person who suffers a sudden heart rhythm disturbance (VF or pulseless VT) from a heart attack or a cardiomyopathy (often undiagnosed, especially in young people) and drops down dead.

· A patient who develops a reversible complication during surgery, eg bleeding.

· An otherwise reasonably healthy person who has a cardiac arrest precipitated by a potentially reversible cause, eg pneumonia, major trauma, tension pneumothorax in an asthmatic, acute intoxication by drugs, drowning in the canal.

A problem arises if we assume that everyone falls into one of these categories. They don’t.

Who is unlikely to benefit from CPR?

· A frail person with advanced dementia and poor mobility living in a nursing home.

· A frail person with all their faculties living in their own home.

· A person with a poor exercise tolerance because of severe chronic heart failure, chronic respiratory disease, a progressive, degenerative neuromuscular disease, or any other debilitating comorbidity.

· A person with advanced liver or kidney disease.

· A frail person who develops a life-threatening acute problem, eg pneumonia, heart attack, sepsis, stroke, major trauma.

· A person debilitated by advanced (incurable) metastatic (Stage 4) cancer.

There are dozens of other examples I could give. The word ‘frailty’ does a lot of heavy lifting in some of the examples given above. It’s defined medically as a loss of physiological reserve and a decline in function across multiple organ systems. It leads to a heightened physical vulnerability, meaning that adverse events (an infection, broken leg, etc) that would be relatively trivial under normal circumstances become life-threatening in a frail individual. Although not an inevitable consequence of ageing, there is a good correlation between youth and physiological reserve. After all, how many superfit 90-year-olds do you know who can beat an unfit 20-year-old in the 1500 metres?

What all these conditions have in common is that they describe a person approaching the end of their natural lifespan. Medicine has yet to find an effective treatment for that particular health condition, which we will all develop in due course. When a person’s heart stops in such circumstances, it usually isn’t a random isolated event that can be treated in isolation. It’s more often the culmination of multiple body systems failing. CPR in this context is trying to reverse the irreversible.

The uncomfortable truth is that there are patients for whom CPR has virtually no realistic chance of restoring meaningful life.

Possible outcomes after CPR

· Resuscitation is successful. The person is discharged from hospital and returns to their normal life.

· Resuscitation is successful, that is to say, the cardiac arrest victim’s heart starts beating again. However, it’s a pyrrhic victory. Their condition rapidly deteriorates immediately afterwards, and a decision is made that any further resuscitation attempts would be futile. A DNACPR form is signed. I would say this was the second most common outcome after a cardiac arrest on one of the general hospital wards that I attended.

· Resuscitation is successful, but the patient remains very poorly. Despite continued active medical management, they die in hospital days or weeks later. Some of them meet the same fate despite being admitted to the ICU and put on a ventilator.

· Resuscitation is successful, but the patient sustains severe irreversible brain damage from oxygen deprivation during the period their heart was stopped. They survive with significant mental and/or physical disability and therefore do not return to a normal life. Some never regain consciousness.

· Resuscitation is unsuccessful. Game over. The patient and their relatives have not experienced a calm, peaceful, dignified death.

In my view, therefore, it isn’t just a case of saying that everyone is entitled to their shot at CPR because there’s nothing to lose. There’s much to lose, which is why responsible clinicians think not only about whether CPR can restart the heart, but whether it can achieve an outcome the patient (and their family) would actually value.

What is a DNACPR?

DNACPR stands for ‘Do Not Attempt Cardiopulmonary Resuscitation.’

Notice the wording. It does not say: ‘Do not treat.’ ‘Do not care.’ ‘Do not comfort.’ ‘Do not help.’ It says one thing and one thing only: If the patient’s heart stops or they stop breathing because they are dying, do not perform CPR. That’s it. A DNACPR decision has no validity, no impact on a patient’s care, until and unless they are dead. Up until that point, a patient with a signed DNACPR order can be admitted to hospital and receive oxygen, fluids, and antibiotics. They can undergo surgery, chemotherapy or dialysis. Whatever. They can even be admitted to the ICU and put on a ventilator. I know because I admitted many such patients myself.

I would like to deal with two aspects of the clinical care of hospital patients that are often confused with DNACPR decisions. They are ‘Defining A Ceiling of Care’ and ‘Treatment Withdrawal’.

Ceiling of care

This is an entirely separate issue from a patient’s resuscitation status should they go on to have a cardiac arrest. A ceiling of care defines the extent of treatment: the medical interventions deemed appropriate and those deemed inappropriate because the likelihood of benefit is far outweighed by the harm. For one hospital patient with pneumonia, the ceiling might include intravenous fluids and antibiotics, facemask oxygen, chest physiotherapy, and nebulised bronchodilator therapy, but not ICU admission or mechanical ventilation. Another hospital patient with pneumonia might not have a ceiling of care, and every intervention is available to them. It might come as a surprise that such a patient might still have a DNACPR order signed.

A third hospital patient with pneumonia might not be actively managed at all and receive end-of-life care, focused entirely on symptom control and their comfort, every effort being made to facilitate a good death. All these patients have a DNACPR form signed as a matter of course.

The crucial point is that these decisions are individual. They’re based on the patient’s underlying acute diagnosis, their chronic health, their frailty, any comorbidities they may have, their prognosis, and likely outcomes. Patients and their families should be involved in these decisions, although they should not make them. They are personally involved and are not the experts. These decisions are made by the medical and nursing staff.

Withdrawal of Treatment

Imagine a critically ill patient in a hospital who has been receiving treatment for an acute medical condition for some time. It could be hours, days or weeks. Depending on their defined ceiling of care, they may be on a general ward or in the ICU on a mechanical ventilator. Despite everything, it becomes clear that recovery is no longer possible. The medical treatment is serving only to prolong the dying process. At that point, the medical team may discuss withdrawing treatment that is no longer providing benefit. Such discussions naturally involve the patient, if they are conscious and have mental capacity. They will generally involve close family members as well.

If it is agreed that withdrawing treatment is the best option, the patient is transferred to an end-of-life care pathway, and a DNACPR form is signed if one hasn’t already been.

Withdrawing a treatment and never starting it in the first place are ethically very similar. If a treatment is unlikely to benefit a patient, doctors are not obliged to provide it simply because it exists.

Okay. I hear you. The issues surrounding a patient’s resuscitation status are more complicated than I thought. But how do doctors decide if a DNACPR order is appropriate or not?

And before answering that, there is the pithy question: why should it be only the doctors who decide? Surely, it’s the patient’s human right to have the final say. Or their families.

Let’s tackle that second question head-on. Why can’t a patient demand CPR, no matter how futile their doctors believe it would be? Under UK law, any patient who has mental capacity can refuse any medical or surgical intervention, or any drug treatment, if they so wish. They don’t have to give a good reason. Or any reason. Provided they fully understand the implications of refusing the treatment advised, they are free to act as they wish. Doctors may not overrule them, no matter how unwise they think the decision may be. Nor can family members!

However, no patient may demand a surgical or medical intervention, or a drug treatment, that their doctors think is not indicated or unlikely to be beneficial. You can’t demand surgery because you think your normal appendix needs to be removed. Neither can you demand surgery for your perforated bowel if your surgeon and anaesthetist are convinced you will not survive. You can’t demand potentially life-saving chemotherapy for your Stage 4 cancer diagnosis if your doctor (or, more likely, NICE) thinks it is not cost-effective. And you can’t demand CPR. CPR is not special in this regard.

Of course, patients should be involved in the decision-making process. It is absolutely worth finding out that the patient does not want CPR. It’s not that uncommon, particularly as people become older and frailer with this and that thing wrong with them. Many, though certainly not all, elderly people recognise their lives are coming to their inevitable conclusion. They have accepted their own mortality and are as ready as they can be for when the time comes. It’s well worth asking the question!

Families should also be involved when a patient’s resuscitation status is being considered (with the patient’s explicit consent, of course). If a DNACPR decision is made, the full reasoning behind it should be explained, and the patient/family members should be given ample opportunity to ask questions. I invariably found that, if you do this, patients and their families accept the final decision, even if reluctantly.

DNACPR orders shouldn’t be seen as a threat. When the process of signing them is done well, they are an opportunity to explain, in open and honest terms, to a patient and their family, what is wrong with them, what the realistic treatment options are, and what medicine can and cannot achieve for them. It’s about using the D word – sensitively and sympathetically, when appropriate. It’s about reassuring the patient that the medical team is doing everything they possibly can to get the patient better, but that if Plan A fails, Plan B will ensure their death is as comfortable, peaceful and dignified as possible.

Final thoughts

CPR is one of medicine’s success stories. It has saved countless lives and continues to do so every day. But it is neither universally effective nor universally appropriate. A DNACPR decision is not about denying care, writing someone off, or deciding their life has less value. It is about recognising that some treatments help in some situations and harm in others. A quiet, peaceful, dignified death is as much a success story as effective CPR.

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Doctors, Nurses, Patients, Hearses

Dr Tony McCluskey — Tue, 16 Jun 2026 00:00:00 +0000

Hospital Managers

Warning: if you are an NHS manager, or married to one, skip this blog post. This is not for you. There’s nothing to see here. Move along, please.

The NHS is a leviathan organisation. It employs well over a million people, making it the world’s fifth largest employer, and spends roughly £200 billion a year on health and social care, about 10% of UK GDP. The NHS obviously needs to be managed, and about a quarter of its employees are either managers or administrative staff. There are NHS managers at national level including the Secretary of State for Health and Social Care, ministers of state for health, under-secretaries of state for health, and DOH civil servants. Myriad organisations manage the NHS top-down, such as NHS England and the allied organisations in the devolved nations, NHS Employers, NHS Providers, the NHS Business Services Authority, NHS Resolution, NHS Digital, and the NHS Confederation. Then there are senior hospital executive managers, middle hospital managers and, further down the pecking order, departmental managers.

When discussing the problems of the NHS, its managers tend to get a bad press. When you have worked in the organisation at senior level for as long as I did, you do gain a certain perspective. I have drawn my own conclusions about the management of the NHS and its managers. What follows is a personal view. You are free to agree or disagree with it as you will. I’m not going to talk about how the NHS is managed at a national level in this post, however. That treat will have to wait. The politicians get a post all to themselves. After all, I’ll need all the space I can get to cram in everything I don’t like about how our elected politicians run our health services.

The Executive Team (execs)

The fight against death and disease is said to take place on the NHS frontline. If the health secretary is the Field Marshall directing strategic operations from a French château miles behind the action in the trenches, then the Executive Team are the senior officer corps, urging their troops to go over the top from the safety of their fortified bunkers. The general commanding the execs is the hospital’s Chief Executive Officer (CEO). The brigadiers and colonels comprising the rest of the Executive Team include any or all of the following: a director of operations; a director of workforce and operational development; a director of communications; a director of strategic planning; a director of finance; a medical director (a senior doctor); a director of nursing (a senior nurse). Immediately below the exalted ranks of the execs are dozens of middle managers, the captains and majors. Under these are countless lieutenants doing their thing in every nook and cranny of the hospital from the ICU to the coffee shop, from the operating theatre to the outpatient clinic, from the Emergency Department to the car park.

The job of the Executive Team is to keep the hospital running, achieving its treatment targets while keeping within its financial budget. In my experience, they weren’t always up to the job and called in external management consultants to advise them whenever the going got tough. These companies always went by flamboyant acronyms such as WNKR Associates, FCKU Creative or BLLCKS Consulting Group. They came up with madcap schemes to save money, such as making senior medical and nursing staff compulsorily redundant, selling off parts of the hospital site for housing development even though that land might be needed in the future, and quadrupling staff car parking charges.

I once suggested to one of our execs that it was actually the Executive Team’s job to do precisely what they’d just brought the external consultants in to do. Weren’t they just a tad embarrassed at not being capable of tackling it themselves? The answer I received was that they were all far too busy firefighting the many acute problems threatening the day-to-day viability of essential services to worry about strategic planning or organisational change. So I suggested they could have consulted the senior medical and nursing staff instead. We would have been much cheaper and would likely have come up with more sensible ideas to develop services and reduce waste and inefficiency in a sustainable way than the so-called experts. Sadly, the NHS is an archetypal top-down organisation, and the notion that the people working on the shop floor might know better than the suits how to improve things doesn’t sit naturally with NHS managers.

Chief Executive Officer (CEO)

CEOs of hospitals are rather like Premiership football managers. They move from hospital to hospital every five years or so, trying to take each one to the top of the league table for four-hour waits in the ED, meeting cancer pathway targets, achieving the best patient satisfaction survey scores, doing more with less, etc. When they first start at a new club hospital, there is a surge in hope, optimism and enthusiasm for a brighter future, at least among the other execs and members of the hospital’s Trust Board, which has just appointed said new CEO (we’ll hear about this talking shop later). The new broom will sweep out the crud and detritus of ingrained inefficiency, lackadaisicalness and poor practice, the Board members think, to be replaced by improved, more streamlined and efficient structures and processes. The end result? Better outcomes for patients? Soaring staff morale? Perhaps. Perhaps not. That’s hardly the point, though. Cost savings are the way forward. And performance bonuses for the managers.

Sadly, reality seldom matches the vision. But then, it really isn’t possible to improve efficiency or increase productivity when everyone is already working their bollocks off, including countless hours of unpaid overtime. When everyone is doing the work of two people, cross-covering the huge gaps in the workforce. The vacancies have remained unfilled for years because nobody wants that much stress and responsibility for so little pay, or because there aren’t the funds to employ replacements. It’s difficult not to be cynical about the airy pontifications of a new CEO and their grand five-year plan when you’re constantly running around like a blue-arsed fly, doing your best to do an adequate job. There was a wall poster in the theatre coffee room with the caption: The floggings will continue until staff morale improves. It wasn’t far from the truth.

As the brand new, shiny CEO tarnishes and the wheels come off the hospital wagon one by one, the writing is on the wall when it becomes clear that none of the clinical targets is being met. The Chair of the hospital’s Trust Board now feels compelled to declare total confidence in the CEO. Speculation is immediately rife about how long the CEO will last. Sweepstakes are organised, gambling on who might take over. The last straw is the publication of the end-of-year financial accounts. The budget has been blown to smithereens. The annual financial deficit has sky-rocketed. Widespread rumours circulate that the hospital will go bankrupt and be taken over by the neighbouring teaching hospital.

Inevitably, the CEO moves on. I say move on, rather than be sacked, advisedly. Returning to the football manager analogy, the CEO departs on the best of terms with the Chair of the Board (they are probably both members of the local golf and Rotary clubs), who publicly thanks the ex-CEO profusely for doing such a sterling job under such challenging circumstances. There is a generous severance payment, naturally, and just like a football manager whose club hasn’t won a trophy yet again this year, the CEO transfers seamlessly to another hospital on an even higher salary. Hey-ho. Nice work if you can get it.

Director of Operations

I haven’t much to say about this role because I was never clear on what a Director of Operations actually did that the CEO wasn’t already supposed to be doing. Perhaps they took turns running things while the other took it easy.

Director of Workforce and Operational Development

They are basically what used to be called personnel or human resources directors, and implement policy regarding the hiring and firing of staff, their terms and conditions of employment, policies on sickness absence, disciplinary matters, remediation, and so on. They do a proper job, one I could understand.

Director of Strategic Planning

It seems to me that this job was a sinecure given that I saw precious little strategy or planning during my hospital career. None that made any sort of sense or involved anything more than the hospital limping to the end of the current financial year without going bust, anyway.

Director of Communications

Their main job is to spread propaganda publish press releases for the local news media, telling the local populace how thoroughly marvellous the hospital is. The recently published, appallingly bad Care Quality Commission (CQC) report should absolutely not be taken at face value. All manner of measures have since been put in place, rendering the 126 pages detailing the special measures to be implemented redundant. What’s more, you can jolly well tell all your readers that the hospital is definitely not in danger of going bust because it can’t afford to pay the electricity bill due next week, even though it may be true that a small number of ventilator-dependent patients on the ICU are reliant on their friends and family putting coins in the recently installed electricity meters.

The Director of Communications also oversees the printing of glossy pamphlets, magazines, and booklets extolling the virtues of the hospital for staff, patients and visitors to read when they’ve nothing better to do. It’s an utter waste of money because nobody ever does read them, no matter how bored they are. The glossies do find use as doorstops, something to lean on while you are writing and as the raw material for making paper planes, though.

Director of Finance

This is the big one! I’ve a lot to say about this, which might come as some surprise, because I know sod all about money, budgets, an organisation’s finances, or how to balance the books while still providing first class clinical services. Funnily enough, those are the self-same traits of your average NHS Director of Finance.

Everybody has a fair idea what being the Director of Finance is all about. I always felt sorry for whichever poor sod was the present incumbent. It can’t be easy for anyone to take on the thankless task of trying to keep an NHS hospital solvent. A poisoned chalice if ever there was one. Why not take on something less stressful and more achievable? Like coaching the England men’s football team to win the next World Cup, for example. Or becoming Kier Starmer’s special advisor, making him so popular in the country that he storms into Downing Street with a landslide victory at the next general election.

Every year we underlings would be informed that we had to make a zillion pounds’ worth of efficiency savings. Every year, the service would be cut not to the bone but through it. When I say service, I mean clinical rather than management activity. And every year it would transpire that the cuts, as brutally savage as they had been, had only saved half a zillion pounds (it would have been more, but a new tranche of managers had to be recruited to oversee the implementation of the cost-saving measures). What it all boiled down to was that next year, two zillion pounds’ worth of efficiency savings needed to be found.

The execs took this caper very seriously, whereas most of us on the frontline thought it was just Alice in Wonderland economics. However, valuable clinical staff with years of knowledge and experience under their belts lost their jobs on the back of this philosophy, being made redundant or resigning under the intense pressure of not having the time or tools to properly care for patients. Equally as important, the NHS lost valuable, irreplaceable clinical staff. Those who remained suffered from low morale and the seeds of their ultimate burnout were sown. The NHS then lost their services, too, when they took early retirement.

This perfect storm could have been so easily avoided if NHS funding and hospital finances had not been so divorced from economic reality and so subject to the political caprices of the government of the day. It took the advent of the COVID pandemic to provide a way out of the financial mayhem in hospitals across the UK, which were severely indebted and at risk of bankruptcy. At a wave of the Health Secretary’s, Matt Hancock’s, magic wand, he disappeared £13.4 billion of historic NHS hospital debt. Every last penny of it was written off at a stroke. Just like that! Tommy Copper couldn’t have done it better. What a pity none of Matt’s predecessors hadn’t waved the government’s magic wand years earlier. Then, perhaps, the NHS wouldn’t have lost so many good people and would therefore have been better prepared and able to deal with the challenges of managing COVID.

Medical Director

The MD is usually a senior consultant in a hospital. It’s their job to ensure that all the doctors working within the hospital are safe, competent and working to established, evidence-based protocols and procedures. Another thankless task if ever there was one. Not for me.

Director of Nursing

A senior nurse or midwife working in a hospital with analogous roles and responsibilities to the MD.

Hospital Board (NHS Trust Board)

The members of the hospital’s Executive Team handle day-to-day operational management, making and implementing hospital policy at a tactical level. However, the execs, including the CEO, are directly accountable to the Hospital Board (usually known as an NHS Trust Board because NHS hospitals are legally defined as self-governing, public sector organisations within the NHS).

Similar to a school board of governors or a corporate board of directors, an NHS Trust Board is the body with overarching strategic responsibility for a hospital, including its performance, long-term planning, governance, CQC compliance, and financial oversight. Crucially, the board is entirely responsible for choosing and appointing the CEO and other members of the Executive Team. It is accountable to NHS England (or analogous organisations in the devolved nations of the UK), the Secretary of State for Health, Parliament, and the local community.

The composition of an NHS Trust board is divided roughly 50:50 between the CEO and other key executive directors on one side, and independent non-executive directors on the other. These independent directors are usually leading figures from the local community, often entrepreneurs and business leaders, or retirees who previously held senior roles in healthcare, education, IT and related fields.

I never worked out what the Trust Board members actually did to earn their corn. It seemed to me that the non-execs merely rubberstamped whatever policies the CEO and Executive Team were pushing. Most people I worked with wouldn’t have been able to name a single member of the Trust Board if their life had depended on it, so divorced were they from life on the NHS frontline. The Chair would appear in a short motivational video on the Intranet from time to time to give a stirring pep talk, motivating the troops to go over the top one more time. The Board members would turn out in force if a VIP was visiting the hospital for any reason. Otherwise, they were pretty much invisible.

Clinical Director (CD)

There are many different clinical departments in a hospital: adult medicine, medicine for older people (previously geriatrics), paediatrics, the ED, obstetrics and gynaecology, surgery (including upper GI, colorectal, orthopaedic and trauma, ENT, urology, maxillofacial, neurosurgery, cardiothoracic surgery, etc), anaesthesia, critical care. All the doctors within a department are managed by a Clinical Director, a senior consultant from that specialty appointed to the role by the CEO. The CD is effectively the CEO’s personal representative within a department and is responsible for departmental performance, protocols and policies, doctor appraisal, disciplinary matters, etc. At least, that’s the theory. In my experience, the CD of most departments was usually chosen by the consultants themselves, based on whose turn it was to be ‘It’. Not many senior clinicians were keen to take on the mantle of manager. Even fewer had the required skill set, and almost none had benefited from any formal management training.

Joint Local Negotiating Committee (JLNC)

The JLNC is the formal forum where the Executive Team meets up with representatives of the medical staff to discuss issues relating to hospital performance and to negotiate doctors’ terms and conditions of employment at a local level. It generally convenes about once every month or two. I know quite a bit about the workings of the JLNC because I was the Medical Staff Side Chair of our JLNC for six years – essentially the hospital doctors’ shop steward. The CEO was the Management Side JLNC Chair. You’ll have heard about people like me in the papers. Apparently I’m a left-wing, extremist, card-carrying member of the British Medical Association (the BMA is the doctors’ trade union), whose primary purpose in life is to bankrupt and destroy the NHS by maximising the already excessively generous pay of fat cat consultants and self-interested junior doctors, at the same time as minimising their workload, by the threat or actuality of industrial action.

In theory, JLNC meetings were chaired alternately by either me or our chief exec. However, most of the time the chief exec had better things to do/couldn’t be arsed/didn’t want to negotiate, and was deputised by the Medical Director, the Finance Director, or the Operational Development Director – whoever had been slowest off the mark to get in their apologies.

My six-year term as Chair was nothing if not educational. I learnt that hospital managers are not half as clever as they think they are. I learnt that negotiation is a tactic to give the impression that managers are listening to concerns and are generally sympathetic to them before imposing whatever it is they want to do, anyway. And I learnt that much of what exec teams strive to achieve over years of endeavour can be superseded at a stroke by the big cheeses above. There can be no better example than Matt Hancock’s magic-wand waving disappearing act of £13.4 b accumulated NHS debt during the COVID crisis.

Check out my website at https://www.drtonymccluskey.com for more details about my books and how you can read free chapters.

My three books, Vocation, Resuscitation, and Resignation, are available to purchase as ebooks or paperbacks at https://www.amazon.com/dp/B0DJ3273KH.

(https://www.amazon.co.uk/dp/B0DJ3273KH for readers in the UK).

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Who's Who and What's What: Inside NHS hospitals

Dr Tony McCluskey — Tue, 9 Jun 2026 00:00:00 +0000

Cardiopulmonary Resuscitation (CPR)

In the last post, we defined what we mean by cardiac arrest and learnt that there are only three cardiac arrest rhythms: shockable, PEA and asystole. We also briefly covered how each of these three arrest rhythms needs to be managed. A shockable rhythm (VF or pulseless VT) must be defibrillated without delay. The reversible causes associated with PEA (the 4Hs and the 4Ts) need to be diagnosed and treated as soon as possible. Asystole usually means it’s game over, although as a lay bystander resuscitating an out-of-hospital cardiac arrest victim it’s never over until the fat lady sings (or the paramedics arrive to take over).

Unless a cardiac arrest victim is in a monitored hospital environment (such as a coronary care unit, ICU or ED resus), the arrest rhythm is shockable, and the patient is defibrillated within seconds, there will inevitably be a delay between the patient collapsing and vital equipment arriving on scene (an ECG/defibrillator, airway/breathing apparatus, adrenaline and other drugs, intravenous fluids, expert help) with which to diagnose the arrest rhythm and appropriately resuscitate the patient. This delay varies from only a minute or two if the arrest occurs elsewhere in an acute hospital to many minutes, perhaps an hour or more, for an out-of-hospital arrest. And as we saw in the last post, the clock starts ticking immediately as the brain, heart and other vital organs are deprived of life-sustaining oxygen. Cue the basic life support (BLS) element of cardiopulmonary resuscitation (CPR).

What is BLS?

There are two elements to BLS: external chest compressions and rescue breathing. However, only resuscitation providers who have been formally trained need concern themselves with rescue breathing. Merely reading this post doesn’t count! I will say a few words about it later, if for no other reason than to reassure you that NOT providing rescue breathing as a bystander in an out-of-hospital cardiac arrest has a relatively small impact on the chances of resuscitation being successful.

External chest compressions

All the while that somebody is in cardiac arrest, they have zero cardiac output. There is no blood flow. The brain, heart and other vital organs are being starved of oxygen. I know I have already said this, but it is such an important point that it bears repeating.

Cardiac arrest never sorts itself out spontaneously. If you and everyone else stand around a collapsed person, look on aghast in shock and horror, and do nothing, the person will stay dead. Their brain, then their heart, and after that their other vital organs, will die off one by one. As I mentioned in my last post, optimally performed chest compressions produce a blood flow of about a third of the normal resting cardiac output. That may not sound so great, but it’s better than nothing. Much, much, much better. It can be the difference between surviving with a good outcome and not surviving at all – or, perhaps worst of all, surviving with a poor outcome.

Every minute’s delay in starting chest compressions reduces a victim’s chance of survival by about 10%, so it’s rather understating things when I say it’s a great shame that bystander CPR is initiated in less than half of all witnessed out-of-hospital cardiac arrests in the UK. You (and yes, I do mean YOU) can join the brave, educated minority and buy time for the victim and their vital organs by performing external chest compressions.

Why do I say brave? Because you have to show real courage, as well as presence of mind and calmness, to take the lead in such a scary, unfamiliar, and literally life-or-death situation. But take heart. You’re braver than you think and, anyway, you cannot possibly make the situation any worse than it already is. You’re looking down at a stiff, after all.

Before moving on to the mechanics of exactly what you should do if you are ever faced with such a bowel-loosening, nausea-inducing nightmare scenario, I want to mention a couple of things about BLS, which in your case is likely to be limited to performing external chest compressions. BLS is not a treatment in itself. Contrary to what you might have seen in films or in TV medical dramas, BLS won’t magically restart a heart that is well and truly stopped. BLS is a holding manoeuvre to keep the arrest victim’s vital organs from suffering severe, irreparable damage while precious time is bought to bring a definitive treatment to bear, such as electrical defibrillation in the case of a shockable rhythm, or to identify and treat one or more of the Hs and Ts.

The chain of survival

This is a sequence of critical interventions, all of which must be carried out in order and without undue delay to give an out-of-hospital cardiac arrest victim the best chance of survival with a good outcome. The chain comprises:

1. Recognise that the victim is in cardiac arrest.

2. Call for help/dial 999/fetch the community AED.

3. Early bystander CPR (BLS).

4. Early defibrillation of a shockable rhythm (using an AED if available).

First things first

Right at the top of the priority list of things to do is safety. Your safety. It’s probably not too risky to approach a person who collapses to the floor in front of you in the middle aisle of your local Aldi, but the same isn’t true if you come across them lying spark out in the middle of a busy road. Or if they’re floating in an icy canal in the depths of winter. Or if there are live electrical cables nearby, and the arrest victim was electrocuted. Wherever you are, don’t rush in heedlessly. The last thing the situation requires is two victims rather than just the one. It only takes a few seconds to evaluate your surroundings. Situational awareness, in the jargon. The first step in the cardiac arrest algorithm asks: Is it safe to approach?

Is the victim really dead?

You don’t need to have studied at medical school for five or six years to recognise if the unresponsive person in front of you is dead. What are the alternatives? Has the person lying prostrate on the ground simply fallen asleep? Unlikely, perhaps, in your local Aldi or in the middle of the A6, but quite possible in the local park on a hot summer’s day. Have they fainted? Have they had a seizure? Are they in some sort of coma, aka they’re as pissed as a fart? If you begin chest compressions without checking them out first, you are quite likely to rouse them abruptly, and they might not be best pleased. So, you need to assess them for signs of life. If they have any signs of life, they aren’t dead. Simples. They might still be seriously unwell, of course, but you’re not going to be jumping up and down on their chest. Call an ambulance instead if you think the situation warrants it.

Signs of life

People always worry about getting this wrong. Don’t worry. It’s honestly not difficult.

First, gauge the person’s responsiveness by kneeling beside them and shaking their shoulders firmly. Shout loudly down both of their ears, ‘Wake up! Are you alright?’ If they wake up and tell you to piss off, they’re not dead. If they respond in any way at all (by moaning and groaning, rolling away from you or trying to push you away), great. They’re definitely not dead.

If they don’t respond at all, check their breathing. Tilt their head back gently by placing one hand on their forehead and the other underneath their chin. This manoeuvre opens their airway. Put your ear down to just above their nose and mouth, and look along the length of their body towards their chest. In this position, you can look, listen and feel for breathing. Take a full ten seconds if necessary, but no longer. Does the chest rise regularly, even if only slightly? Can you hear breath sounds? Can you feel their breath on your ear? If the answer to all three questions is no, as far as you or anyone else is concerned, the person is dead.

When I mentioned breathing, just now, I specified regular breathing. If the victim is making only occasional, irregular, deep gasps like a fish out of water, they’re exhibiting what’s unhelpfully termed agonal breathing. It happens when a dying brainstem sends desperate, erratic nerve signals to the lungs. Agonal breathing looks and sounds as bloody awful as it is effective. Your victim is dead. If you are in any doubt whatsoever about whether what you are looking at really is agonal breathing, assume the worst. You are most unlikely to cause serious harm by performing chest compressions on somebody who doesn’t need it, but you definitely will allow serious harm to develop unchecked if you don’t perform them for someone who does.

But what about checking for a pulse, I hear you all cry? Sod that! Don’t waste time. Get on with it. I’ll explain later.

Okay, they’re definitely dead. What should I do next?

The answer to this question is, at first sight, obvious – resuscitate your patient. But that isn’t what you should do next. Remember, BLS is only a holding manoeuvre to buy time for the brain, heart and other vital organs while expert help arrives to definitively treat the cardiac arrest. The immediate priority is to ensure that such help is sought.

If you’re in the middle of a supermarket, a curious crowd of onlookers will undoubtedly have gathered to ogle what’s occurring. One of them can call for help. But don’t just yell into the ether, ‘Can somebody call for an ambulance, please?’ There is a phenomenon called the ‘Bystander Effect’ at work in emergency situations involving lay members of the public. Everyone is agitated and confused. People adopt the easy route by assuming someone else will take care of the problem while they film the scene on their phones for their next social media post or continue shopping. Instead, point aggressively at an individual you think may be relied upon, lock eyes with them and order them in no uncertain terms, ‘You with the trolley crammed full of wine and beer, call 999 right now and tell them we have a cardiac arrest. Then find out if there’s an AED nearby and bring it here as soon as you can. Have you got that?’ Keep staring at them until they indicate that they have received and understood your instructions and will carry them out.

If you’re in the middle of the park, however, there might not be any other people immediately in view. Shout as loudly as you can for help. If none appears, dial 999 yourself using your mobile. Put it in speaker mode and place it on the ground next to you. When the operator answers, they will ask what service you require. Your answer should be a clear, crisp, ‘Ambulance. I’m with an unconscious adult who is not breathing. I know how to perform external chest compressions.’

Assuming that last sentence is true (because you’ve read and digested this blog), you will already have started chest compressions. If it’s not because you skim-read this blog (naughty, naughty) and have forgotten it, or you simply don’t feel confident, the ambulance call handler will direct you. They will keep you calm and on task. They will encourage you. They will help you to perform effective chest compressions at the correct rate and with the required force. So don’t hang up on them once they inform you the ambulance is on its way!

If you don’t have mobile phone signal (or even a mobile phone on you), you must leave the victim and do whatever you can to summon help as quickly as possible. I know, I know. It sounds counter-intuitive, and it must be agonising to abandon a cardiac arrest victim. However, summoning expert help is the next essential link in the chain of survival. No matter how difficult, it really is what you must do. You will not help the victim by performing external chest compressions until you are exhausted. BLS is not a definitive treatment for cardiac arrest.

As I suggested earlier, summoning expert help is not the sole priority. These days there is increasing availability of community defibrillators (actually, AEDS – automated external defibrillators). It will sometimes be the case that one of these can be used to successfully resuscitate a person in a shockable rhythm before the paramedics even arrive on scene. We’ll go over how you use an AED shortly. It’s dead easy! So make sure someone is fetching the nearest one.

External chest compressions

Okay. You’ve recognised that the person splayed out on the floor next to you is dead, help is on the way, and somebody has been dispatched to the library across the road outside which there is an AED attached to the wall. It’s time to get down to the real work. And I do mean work.

The method of cardiac resuscitation by performing external chest compressions was discovered accidentally in 1960 during experiments on dogs. Ever since, chest compressions have remained the mainstay of basic life support resuscitation. High pressure is generated within the chest cavity with each downward compression. That pressure is transmitted through the heart, forcing blood out of the chest and into the great arterial blood vessels. Blood flows forward rather than backwards because the heart valves allow only one-way traffic. During the passive elastic recoil of the chest wall that immediately follows, negative pressure generated in the chest draws blood in from the veins that drain the body and lungs, priming the heart chambers for the next compression.

For chest compressions to be effective, they must be applied in the right area, be forceful enough, be quick enough, and be uninterrupted. This is because it takes several compressions to build up a head of pressure in the arteries to promote forward flow, which drops rapidly to zero the instant you stop compressing. Even so, the best blood flow you can expect with optimal-quality chest compressions is about a third of the normal cardiac output. But it’s enough to keep the brain, heart and other vital organs ticking over for a limited period of time.

Let’s look at each of these elements of effective chest compressions in turn.

Correct hand position

Kneel beside the cardiac arrest victim, close enough that your shoulders can easily be positioned above their sternum (breastbone). Find the centre of their chest. Don’t overthink this. It’s midway between the nipples (although do bear pendulous breasts in mind). Place the heel of one hand over that spot. Now place your other hand directly on top of the first and interlock your fingers. Only the heels of your hand should be in direct contact with the sternum. Your arms should be held straight, your elbows locked.

Force required (depth) and rate

Hard and fast is the rule. Hard enough to compress the chest by 5 cm (2 inches) at a rate of 100-120 compressions per minute (roughly 2 per second).

The force required for chest compressions to be effective, and the physical effort required from you, shouldn’t be underestimated. People who rarely need to perform CPR for real (including some trained doctors and nurses) worry about causing serious injury by pressing down too hard. It’s a fair point, but the victim of a cardiac arrest is much more likely to be damaged by ineffective chest compressions that are too airy-fairy.

Remember to allow the chest to fully recoil upward to its normal resting position by completely relaxing the tension in your arms at the end of each compression. Don’t remove your hands from the victim’s chest. Just lift your weight sharply off. This passive component of CPR is just as important as the active component.

The acknowledged gold standard method for performing chest compressions at exactly the required rate, in the absence of a metronome that you always carry around in your back pocket for just such emergencies, is to work to the beat of Stayin’ Alive by The Bee Gees, which you can sing or hum as you go. If you’re feeling more pessimistic about the final outcome, Another One Bites The Dust by Queen does the same job.

Did I mention that CPR is hard work? If you’re putting enough welly into your chest compressions, it should be really tiring, even exhausting, after more than a few minutes. This is why the resuscitation team member performing chest compressions during a hospital cardiac arrest is rotated at two-minute intervals. Unless you’re lucky enough that somebody else in the Aldi crowd knows how to perform CPR, you’re on your own.

Hopefully, for you (and the poor sod who’s arrested), one of two things will happen before you collapse in a heap from fatigue. Ideally, the paramedics will arrive. Job done. A quick handover and you can head over to the drinks aisle. No need to wait until you’ve paid at the checkout before you down a slug of gin. The second option is that somebody pitches up with an AED. Great. The odds of successfully resuscitating your patient have just skyrocketed.

You can find AEDs in shopping centres, leisure centres, gyms, sportsgrounds, bus and train stations, wherever. They are often mounted on exterior walls to ensure they are available 24/7. They’re even installed in repurposed red telephone boxes. In fact, you’ll find AEDs just about anywhere people congregate. There’s probably one close to where you live. Find out where it is and tell your partner – just in case you need it one day!

Automated External Defibrillators (AEDs)

Many people are scared at the thought of having to use an AED. They worry that they won’t be able to operate it correctly. What if I can’t get it to work? What if I shock the patient inappropriately and cause them harm? What if I accidentally electrocute either myself or a fellow bystander? These fears are understandable but entirely unfounded. An AED can’t double up as a satnav. It can’t load up the internet for you. It can’t make you a nice cup of tea. An AED can do one thing and one thing only: it safely manages a cardiac arrest, giving you clear, unambiguous instructions at all times until help arrives or the victim revives. It will absolutely not charge up unless it detects a shockable rhythm, so it’s impossible to defibrillate inappropriately. It’s also impossible to electrocute yourself or anyone else.

While you are opening the AED box and applying the gel pads, have someone else perform chest compressions, after you have demonstrated how to do it. You probably need a breather by now, anyway. Alternatively, get them to deal with the AED.

You usually switch the AED on by pressing the great big, clearly labelled power button. Some machines do it automatically when you open the case’s hinged lid. Follow the AED’s verbal instructions to apply the sticky gel pads firmly to the victim’s bare chest. There will be idiot-proof diagrams on the outer packet of the pads and on the AED’s inner lid telling you where to position them. The AED will then continue to guide you with step-by-step, clear, simple instructions. You simply cannot get it wrong.

The next thing the AED will instruct you to do will be to halt chest compressions and take your hands off the victim while it analyses the heart rhythm. It’s your job to make sure nobody else is touching the victim. If a shock is advised, it will announce that fact and begin charging. You may hear a high-pitched whine. An illuminated button will flash when the AED is fully charged. With a final visual sweep to ensure nobody is touching the victim, shout ‘Stand clear’ in a voice that brooks no argument, then press the button.

The victim’s body will twitch violently as electrical current passes through it. This is entirely normal. As soon as the shock has been delivered, the AED will verbally instruct you to resume chest compressions for two minutes, after which you’ll get a breather while it reanalyses the heart rhythm.

If no shock is advised when the AED is first attached, it will announce that to be the case and tell you to resume chest compressions for two minutes. Don’t worry – it’s keeping an eye on the clock for you.

You keep following the machine’s instructions until the cavalry finally charges up to the rescue. Unless, of course, you and the AED have already effected a miracle and your patient is sat up, looking bemusedly around and asking, ‘Are there any wines of the week left?’

When do you stop BLS?

There are three circumstances where it is appropriate for you to stop.

1. Expert help arrives and takes over from you. Keep going until a paramedic physically lays their hands on the victim’s chest.

2. The victim rouses or shows any signs of life. Congratulations. You’ve saved a life.

3. Physical exhaustion sets in. If you are alone in a remote location, you will reach a point when you simply cannot continue. Performing high-quality chest compressions is physically demanding, akin to an aggressive gym workout. Before you feel compelled to throw in the towel, however, the quality of your compressions will already have dipped and become less effective. I conducted some clinical research back in the day that showed the quality of chest compressions declined within as little as two minutes.

It all sounds so simple. Is that really all there is to it?

It really is that simple. Well, pretty much. I probably should tell you about a couple of things:

Pushing down hard on someone’s sternum can be traumatic. You may hear and feel ribs snapping. It’s deeply unsettling, and your immediate reaction is to back off and stop because you think you are harming the victim.

DO NOT STOP. A broken rib heals in a few weeks. A dead person stays dead forever.

Another unsavoury aspect of dealing with cardiac arrest victims is that acute hypoxia (oxygen deprivation) causes the body’s sphincters to relax. While it may be messy and a bit smelly at the bottom end, you can ignore it for the moment. Top end action can’t be ignored, however. It is not uncommon for people in cardiac arrest to vomit or have gastric fluid pool at the back of their throats, which then overflows from their mouths. You don’t want this fluid to get into their lungs. If this happens, don’t panic. Swiftly tip the person onto their side and let gravity do the work of clearing their airway. Then roll them back and resume chest compressions.

Common myths debunked

The precordial thump

This is when you wallop the victim in the chest with your fist right at the start. You may have watched impossibly handsome doctors in TV dramas do this with miraculous results. Don’t do it!

You’ve not mentioned checking for a pulse. Surely, it’s vital to check the victim does not have a pulse before starting CPR?

I said I’d come back to this. In a highly charged medical emergency, your adrenaline level will be through the roof, and your heart will be galloping madly. In this situation, even experienced doctors and nurses can struggle to find a carotid pulse, and they know precisely where to palpate. The throbbing pulse in your own fingers will interfere with anything there is to feel (or not) in the patient’s neck. If you muck about for a couple of minutes thinking, ‘Is that the victim’s pulse I can feel?’ you might as well pack up and go home.

Forget a pulse check. If the victim is collapsed, unresponsive and not breathing, they’ve checked out. Cashed in their chips. Popped their clogs. Kicked the bucket. Shuffled off their mortal coils. Gone to meet their maker. They’re dead, you idiot. Start chest compressions.

If it all goes horribly wrong, I’ll get sued

It can’t get any more wrong than being dead.

Having said that, there are lots of things you don’t know about the complete stranger who has collapsed in front of you. Do they have a terminal disease that makes resuscitation inappropriate? Is it the victim’s wish that they not be resuscitated in the event of a cardiac arrest for whatever reason? Do they have a community DNACPR signed off? You cannot know any of these things. You simply have to act in good faith and assume that attempting to resuscitate them is the right thing to do. No bystander has ever been successfully sued in the UK for performing CPR in good faith. You are fully protected under the law by the concept of the Good Samaritan.

The other thing you’ve not mentioned is rescue breathing – this must surely be an oversight

No, I haven’t forgotten to mention it. There are several reasons why rescue breathing is not advocated for bystander CPR. Mouth-to-mouth ventilation (the only option usually available to Joe Public) is unpalatable to most people, particularly if the victim has vomited. Mouth-to-mouth rescue breathing is also technically difficult to perform effectively without proper training. If all that isn’t bad enough, combining effective rescue breaths and chest compressions can make the whole resuscitation thing seem just so complicated and off-putting that it discourages people who might otherwise be keen to attempt resuscitation.

What’s more, compression-only BLS can be almost as effective as compression-ventilation BLS, at least for a period of time after somebody suffers an out-of-hospital cardiac arrest. How can this be true?

Well, to start with, the concentration of oxygen in the expired air from your lungs is a paltry 16% compared with the 100% a hospital resuscitation team can provide by manually ventilating a patient with a bag-valve-facemask apparatus connected to an oxygen cylinder. Secondly, although the lungs and red blood cells have limited capacity to store oxygen, there is enough to keep vital organs reasonably supplied for a few minutes until help arrives. Thirdly, vigorous chest compression, followed by its expansion during passive elastic recoil, generates some movement of atmospheric air (containing 21% oxygen) in and out of the lungs – provided the patient’s airway is held open by someone.

One last question: what about children?

I was hoping you wouldn’t ask that. It’s a very good question. From a physiological perspective, children are not simply scaled-down adults. Babies even less so. It’s also the case that young people seldom drop down dead of heart-related conditions. There are much more likely to be special circumstances involved, such as drowning, severe asthma, major trauma, etc. CPR for small children and babies differs fundamentally from adult CPR because children require rescue breaths. Tackling paediatric resuscitation is outside the scope of this article. However, please read the next short paragraph carefully.

If a collapsed, unbreathing, unresponsive child appears to you to have reached puberty (looks to be about 11 or 12), resuscitate them in exactly the same way as you would an adult. If you are confident about providing rescue breaths, go for it at a ratio of 30 compressions to 2 rescue breaths. Even if they are younger, there’s really nothing to be lost by attempting to perform external chest compressions, using only one hand for small children and babies.

Summary

1. Think safety first.

2. Assess response.

3. Shout for help. Call 999. Dispatch somebody to fetch an AED.

4. Perform chest compressions. Don’t stop unless an AED instructs you to, the patient shows signs of life, help arrives, or you are exhausted.

5. Attach the AED and follow its prompts.

6. Whether the victim lives or dies, regale all your mates in the pub afterwards about your heroic exploits. You won’t have to buy a round all night.

Well done for making it to the end of this post. You could save a life. It might be mine! Now, go back to the beginning and read through it once more to ensure you’ve understood all of the key points.

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Who's Who and What's What: Inside NHS hospitals

Dr Tony McCluskey — Sun, 31 May 2026 00:00:00 +0000

Heart attacks and cardiac arrests (Part 2)

Cardiac Arrest

In the last post, we defined cardiac arrest as the sudden, unexpected collapse of the heart’s mechanical pumping action that is potentially reversible. In this post, we’ll look at some of the causes of cardiac arrest, what types of cardiac arrest benefit from the use of a defibrillator, and the principles of resuscitation. In the next post, I’ll take you through the mechanics of how to perform cardiopulmonary resuscitation CPR if you are unlucky enough to be in the immediate vicinity when somebody nearby croaks it. In the one after that, we’ll consider circumstances in which CPR may be inappropriate and the application of Do Not Attempt CardioPulmonary Resuscitation (DNACPR) orders.

What happens immediately after a cardiac arrest (if you do nothing)?

The consequences of cardiac arrest are as predictable as they are dramatic. Arterial blood pressure plummets rapidly to zero, and forward blood flow through the circulation grinds to a halt. Our brains normally receive 750ml/min of oxygenated blood, which equates to fully 15% of the entire cardiac output of 5L/min, even though the brain accounts for only 2% of total body weight. This is true whether you’re concentrating hard during an exam, daydreaming, sleeping or even reading The Sun. Unfortunately, our brains have essentially zero capacity to store oxygen, and consciousness is lost within seconds of cerebral blood flow ceasing.

The clock starts ticking immediately as brain cells suffer the consequences of oxygen deprivation. One of the first vital neuronal centres to throw in the towel is the respiratory centre, located in the brainstem. Breathing stops soon after the heart stops, although the victim may take irregular gasps, known as agonal breathing, for a minute or two. I should add that some cardiac arrests are caused by somebody stopping breathing first – a heroin overdose, for example.

If the heart is not restarted and the circulation is not restored within three or four minutes, irreversible brain damage occurs. If the heart does eventually get going again after this time, the victim will suffer from permanent brain injury. The severity of such brain injury depends largely on the duration of the downtime (see later). The signs may be relatively subtle after a short downtime – forgetfulness, difficulty concentrating and personality changes. At the other extreme, permanent, catastrophic, global cerebral dysfunction, characterised by the complete absence of conscious thought, intellectual function and even self-awareness, is the end result. Although a person suffering such severe brain damage can breathe for themselves unaided, open their eyes, digest their food, exhibit sleep-awake cycles and make simple reflex responses such as blinking in response to a loud noise, they are incapable of the higher cerebral function that made them the unique person they once were. This condition used to be called a Persistent Vegetative State (PVS), although other terms such as Post-Coma Unresponsiveness (PCU) are now preferred. PCU is often confused with being brain dead, but the two conditions are entirely different, as we shall see in a later post.

Just to clarify what we mean by the downtime, there are, in fact, two downtimes. The first is the length of time from the onset of cardiac arrest to the delivery of effective CPR. During this period, there is zero blood flow in the circulation (including the brain). The second is the time from the onset of CPR to the restoration of a spontaneous circulation. During this period, there is low blood flow in the circulation (including the brain). Even with optimally performed external chest compressions, it is only about a third of normal during cardiac arrest.

Why has the heart stopped pumping?

All cardiac arrests are equal (you are technically dead, regardless), but some cardiac arrests are more equal than others (have better odds of successful resuscitation).

While it’s never a good idea to be on the receiving end of any flavour of cardiac arrest, it does pay to go down with some types rather than others if you want the best chance of springing back to life. In descending order of resurrection potential, the three types of cardiac arrest, based on the presenting ECG heart rhythm, are: 1. Shockable ECG rhythms. 2. Pulseless Electrical Activity (PEA). 3. Asystole.

Before we discuss abnormal ECGs, it would be useful to know what a normal ECG looks like. Here is the typical ECG of a heart beating normally. I’ve only shown a single heartbeat to keep things simple:

It’s a more or less horizontal, slightly undulated, flat line, signifying the absence of any electrical activity in the heart. Nada. Zilch. It is usually an indication that the heart has suffered so badly from prolonged oxygen starvation after a long downtime that it’s thrown in the towel. Unless there are special circumstances, the heart is beyond recovery. Attempting to resuscitate an asystolic heart is a waste of everybody’s time and an undignified way to go.

I said earlier not to worry if you don’t know how to interpret ECGs. I knew many doctors who didn’t have a clue, either – most of them orthopaedic surgeons. All you need to know about ECGs in the context of a cardiac arrest is that there are three, and only three, heart rhythms to recognise and deal with:

1. Shockable rhythms (VF and VT) – defibrillate.

2. PEA – treat the cause.

3. Asystole – put the kettle on.

The even better news is that you don’t even need to know that much if you ever find yourself in a situation where you are resuscitating a victim of an out-of-hospital cardiac arrest. As we will see in the next post, if you have access to an automatic external defibrillator (AED), it will diagnose the rhythm and instruct you to defibrillate only if your patient is in VF or VT. Otherwise, it will simply tell you to hold the fort (continue chest compressions) until the cavalry arrives (probably in an ambulance rather than on horseback).

How to treat PEA

The chances of successfully resuscitating somebody who has arrested in PEA are less than those of somebody in VF or VT, but much better than those of somebody in asystole. The outcome depends on the exact cause of the cardiac arrest and its reversibility (how amenable it is to targeted treatment), as well as on early identification and appropriate treatment. If you can’t identify and treat the cause, the victim’s a goner.

The eight classical causes of PEA, familiar to doctors, nurses and paramedics everywhere, are known as the 4Hs and 4Ts. The 4Hs are: hypoxia, hypovolaemia, hypothermia and hypo/hyperkalaemia (and other severe metabolic disorders). The 4Ts are: tension pneumothorax, tamponade, thromboembolic disorders and the toxic effects of drugs (prescribed or illicit).

CardioPulmonary Resuscitation (CPR)

I’m going to cover this topic in more detail in the next post. I mention it here to put defibrillation and identifying/treating the 4Hs and 4Ts into context. All the while that your patient is in cardiac arrest, they have zero cardiac output. There is no blood flow. The brain, heart and other vital organs are being starved of oxygen. While the victim themselves is technically dead, their organs aren’t. Yet. You can buy time for these organs by performing CPR – external chest compressions (+/- rescue breathing, but only if you are a trained first responder). Optimally performed chest compressions produce a blood flow of about a third of the normal resting cardiac output. That may not sound so great, but it’s better than nothing. Much, much better. It can be the difference between surviving with a good outcome and not surviving at all – or, perhaps worst of all, surviving with a poor outcome.

That’s all, folks. Although if you’re a glutton for punishment and insist on knowing more about the 4Hs and 4Ts, read on. Otherwise, you can call it a day. See you in the next post.

The 4 Hs

Hypoxia

Hypoxia is a medical condition in which the body’s organs and tissues do not receive enough oxygen to function properly. The most common causes are diseases of the lungs, such as pneumonia, COPD and acute severe asthma, or inadequate respiratory effort, for example, after taking a heroin overdose. Your two most important organs (yes, I know they’re all kinda important), your brain and your heart, happen to be the two most vulnerable to the effects of hypoxia. Whoever designed the human body got that one wrong.

The treatment of hypoxia often requires mechanical ventilation even after the successful return of a spontaneous circulation.

Hypovolaemia

Hypovolaemia is a medical condition characterised by the severe depletion of circulating blood volume. Acute major haemorrhage is an obvious cause. It may also occur in conditions where fluids and electrolytes are lost faster than they can be replaced, for example, prolonged water deprivation, severe diarrhoea, severe vomiting, and sepsis.

The treatment of hypovolaemia involves the intravenous infusion of blood, fluid and electrolytes. It’s also essential to control bleeding, even if this requires taking a critically ill/dead patient to the operating theatre.

Hypothermia

Your body’s core temperature is normally maintained at around 37ºC, even when you’re throwing snowballs at your kids on a cold winter’s day. Your fingers and toes may feel frozen, but your vital organs, nestled deep down under protective layers of skin, connective tissues, bone, and fat, remain warm and toasty. Things have gone badly wrong if your core temperature drops below 35ºC, the threshold definition of hypothermia. Perhaps you became lost in a blizzard and can’t find your way to shelter (it happens). You will feel uncomfortably cold, experiencing a deep, penetrating ache in your arms and legs. You will be shivering madly. You will become clumsy and lose coordination. Still, such mild hypothermia is hardly likely to trigger a cardiac arrest.

As your core temperature dips further, you become confused. You can’t think straight. Your speech is slurred. You feel increasingly tired and are overcome by the feeling that you really can’t be arsed (actually, that’s how I used to feel on most days until I retired). Your heart rate tends to slow gradually as your body cools, until it grinds to a halt as severe hypothermia sets in at a core temperature below 30ºC. Alternatively, your heart might take matters into its own hands before then and decide to end it all by going into VF.

Although exposure to the elements in blizzard conditions is an obvious potential cause of severe hypothermia, you are just as likely to die of hypothermia after falling into the canal in the middle of February as you are from drowning. Or if you fall asleep, blind drunk, en route from pub to home late one night in the middle of January.

From one perspective, hypothermia is a good way to end up in cardiac arrest because brain metabolism decreases with temperature, which means much longer downtimes can be survived with a good outcome. People have been fished out of freezing water in severe hypothermic cardiac arrest more than an hour after falling through the ice and have subsequently been successfully revived with full neurological recovery. Attempts to resuscitate such victims are therefore often continued for much longer than for most other cardiac arrests.

It takes a long time for the body to warm up enough for the heart to have a chance of restarting, often several hours. This fact has given rise to the old saying in resuscitation medicine that you’re not dead until you’re warm and dead. It doesn’t apply, though, if old Mrs Jones, who hasn’t been seen for several days, is found stone cold dead in her house and rigor mortis has set in.

Hyper/hypokalaemia (high and low serum potassium) and other electrolyte disturbances.

This H is a hodgepodge of severe metabolic disturbances. I’m not going to go into any detail about them, otherwise we’d be here all day. Suffice it to say that you need to treat the metabolic abnormality. For example, if a very high serum potassium has caused cardiac arrest (as it may in a person with acute kidney failure), intravenous drugs must be given PDQ both to reduce the serum potassium level and to neutralise the toxic effect of the potassium on the heart.

The 4 Ts

Tension pneumothorax

A tension pneumothorax occurs when air accumulates in the normally empty pleural space outside and surrounding the lung, and develops such a high pressure that it compresses the heart, preventing it from pumping blood effectively. It also collapses the affected lung. A tension pneumothorax is usually caused by major chest trauma. Attempts to resuscitate the victim of a tension pneumothorax in cardiac arrest will fail unless the pneumothorax is rapidly diagnosed and decompressed. Basically, you stick a large cannula through the skin between the second and third ribs, in a line running down from the middle of the collar bone, deep enough to enter the pleural cavity and vent the high pressure. An audible hiss is what you classically hear. However, with all the noise and pandemonium going on during a regular cardiac arrest resuscitation, you’d be lucky to hear Krakatoa erupting if you were the on-call anaesthetic registrar at Jakarta General Infirmary.

Tamponade

The heart does its stuff, sitting in a bag called the pericardium, which contains a small amount of fluid that acts as a lubricant, reducing friction between the beating heart and adjacent structures. It’s cardiac WD40. Cardiac tamponade occurs when an abnormal volume of fluid accumulates within the pericardium, preventing the heart from filling and emptying normally. Being stabbed in the heart will do it, in which case the abnormal pericardial fluid is blood.

To say that diagnosing tamponade during a cardiac arrest is tricky is an understatement – unless you happen to be a whizz with ultrasound and you have a machine handy. Even then, it’s far from easy. Having a high index of suspicion for cardiac tamponade is key when a patient arrests after chest trauma. Simple if there’s a great big knife sticking out of the front of the victim’s chest when they’re wheeled into the ED, but perhaps less so after they’ve been run over by a bus and their most obvious injuries are two mangled legs.

Opening the chest (emergency thoracotomy), decompressing (opening) the pericardium and performing internal cardiac massage by squeezing the heart directly with your hand greatly improve the chance of survival. It’s a big call, messy and not for the faint-hearted, but there’s nothing to lose. The victim is already dead, after all.

Thromboembolic

There are two thromboembolic causes of cardiac arrest: coronary artery thrombosis and massive pulmonary embolism. The first is basically your common or garden heart attack. Although there’s not usually much that can be done to unblock the affected coronary artery to restore blood supply to the heart during cardiac arrest, if resuscitation is successful, the patient may be rushed to the cardiac catheter lab for a percutaneous coronary intervention (PCI), a stenting procedure of the affected artery/arteries, and/or be given an intravenous infusion of a clot-busting drug such as alteplase.

Massive pulmonary embolism occurs when a large blood clot (thrombus) that has developed in a vein in the pelvis or one of the lower limbs breaks off and is carried along the venous circulation until it lodges and gets stuck, usually in the heart, causing a more or less total obstruction to the onward flow of blood. Risk factors include cancer, pregnancy, major trauma, recovery from major surgery and prolonged immobility. Although vigorous chest compressions can sometimes mechanically break up the thrombus, acute PE is more definitively treated by administering a clot-busting drug during resuscitation.

Toxins

Toxins that may cause cardiac arrest include prescribed medications taken in overdose (sedatives, antidepressants, opioid analgesics, high blood pressure medication, etc), illicit drugs (heroin, cocaine), not-so-illicit drugs (alcohol) and allergens such as peanuts in susceptible individuals. In many situations, there isn’t a specific antidote, and good quality CPR with supportive treatment is the way forward.

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Who's Who and What's What: Inside NHS hospitals

Dr Tony McCluskey — Sun, 24 May 2026 00:00:00 +0000

Heart attacks and cardiac arrests (Part 1)

In the next two or three posts, I want to talk about some acute cardiac conditions that people have usually heard of but are often a bit unclear about, or even completely misunderstand. The list includes heart attacks, heart failure, shock, cardiomyopathy and cardiac arrest.

Heart attacks

There are more than 100,000 heart attacks in the UK each year. The good news is that more than 7 out of 10 victims live to tell the tale. Actually, it’s really great news because when I first embarked on my medical career, the exact same proportion of heart attack victims died. The vast improvement in the outlook during the past 30-40 years probably isn’t all down to me, but just saying. The bad news is that if you are unlucky enough to have an out-of-hospital cardiac arrest as a consequence of your heart attack, your chances of survival are less than 1 in 10.

Is a heart attack the same as a cardiac arrest?

The answer is no. Although heart attacks may present as cardiac arrests, not all heart attacks cause cardiac arrest, and there are other causes of cardiac arrest apart from heart attacks.

What is a heart attack?

A heart attack is a life-threatening, acute medical emergency that occurs when blood flow to a part of the heart is suddenly either severely reduced or completely blocked. I learnt pretty quickly after I started doctoring that, as far as the patient, their friends and relatives were concerned, there were only two types of heart attack that they needed to know about: small ones, which you survived, and massive ones, which killed you.

There is a whole lexicon of alternative terms available for heart attack, including myocardial infarction, MI, acute myocardial infarction, infarct, coronary thrombosis and the even simpler coronary (because the cause of a heart attack is usually a blocked coronary artery). Whatever you care to call it, the heart takes a dim view of not receiving the full quota of blood it was expecting, along with the oxygen and nutrients carried in the bloodstream. It responds with a hissy fit. Well, you can hardly blame it.

What causes the interruption in blood supply to part of the heart in a heart attack?

Your heart is basically a globular muscle about the size of your fist, with four one-way valves and some electrical circuitry inside. It functions as a hydraulic pump with a flow rate of 5 L/min. Like any other pump, the heart requires a source of energy to power it. To keep its engine running smoothly for the approximately 3,000,000,000 (3 billion!) beats of an average human lifespan, it must receive a steady supply of blood to deliver the oxygen and nutrients necessary to feed its energy metabolism.

Although all the blood coursing through your body passes through the four chambers of your heart, only a relatively small proportion of the total blood flow is siphoned off to supply the heart itself. A healthy heart at rest receives about 250 ml/min oxygenated blood, which is about 5% of the total cardiac output. During vigorous exercise, this figure may increase fivefold. All this blood flows through the coronary arteries, whose internal diameter is 3-5 mm. I’ll repeat that. The blood that keeps your ticker ticking flows through channels just 3-5 mm wide.

There are two main coronary arteries: the left and the right. The left main coronary artery soon divides into two branches. It does most of the heavy lifting because it supplies the left ventricle, which does a lot of work generating the high pressure needed to pump blood around the body. The right main coronary artery has a cushy number in comparison, supplying blood to the right ventricle, which only needs to pump blood around the lungs, which is a low pressure circulation. Complete occlusion of the left main coronary artery is sometimes called the ‘Widowmaker’. It more often results in massive heart attacks, cardiogenic shock (see later) and death.

By now, readers will be loudly shouting at their phones or computer screens that there are four chambers in your typical heart, and I’ve made no mention of the two atria. This isn’t an oversight, although I was being simplistic in my explanation. While atrial contraction does help to prime the ventricles with a full load of blood ready for the next contraction, the atria actually do very little work even on a good day, and you can manage reasonably well without them – as many people with atrial fibrillation will tell you.

When we are born, our coronary arteries are pristine. However, unless you are particularly fortunate in the genes you inherit and/or have parents who deny you any and all fatty, additive-laden food, force you to exercise for eight hours a day throughout your childhood, and starve you whenever your BMI rises above 18.5, your coronary arteries are already showing signs of atherosclerotic damage by the time you reach adulthood. Atherosclerosis is a progressive, degenerative arterial disease characterised by the deposition of fatty cholesterol plaques in blood vessel walls. By the time you’re forty, if you’ve not looked after yourself, you lead a sedentary lifestyle, you’re overweight or obese from too many kebabs, burgers and chicken vindaloos, you like a drink or two, and, God forbid, you smoke, those coronary arterial channels (which, remember, are only 3-5 mm wide to begin with) could well be dangerously narrowed by sticky, gloopy, fatty plaques. You’ve turned into a walking MI, and you didn’t even know it because you feel fine. You’re a ticking time bomb, and it’s only a matter of time before it goes off. Did that scare you? It certainly scared the shit out of me. The diet starts tomorrow. And I’m joining a gym.

It follows, of course, that if you do look after your heart by exercising regularly, eating a well-balanced nutritional diet and maintaining a healthy weight, by not smoking at all and drinking alcohol modestly, you are less likely to suffer a heart attack. And even if you are unlucky and the worst should happen, your heart is in much better shape to survive the insult and recover. This begs the question, though, why do some ultrafit, young, elite athletes with no history of heart disease or anything else have a heart attack?

To understand why, you have to appreciate that coronary arteries block off in one of two distinct ways. In most cases, atheromatous plaques build up gradually over the years. Disease progression is accelerated by factors such as high blood pressure, obesity, high cholesterol, diabetes and smoking. Until roughly three-quarters of the internal lumen of an artery is obstructed, blood flow along it is not significantly impeded, and the atherosclerosis is therefore asymptomatic. As the degree of obstruction progresses further, angina may develop. The person experiences chest pain on exertion because the increased metabolic demands of the exercising heart muscle cannot be met by increasing the coronary artery blood flow. Angina pain is rapidly relieved by resting.

An elite athlete, on the other hand, may only have 20% narrowing of a coronary artery. It’s inconsequential to their performance. But whilst such small plaques do not impede coronary blood flow at all, they are like dormant volcanoes. Atherosclerotic plaques are inherently unstable. At any moment, they can rupture, triggering the formation of an instantaneous blood clot that completely occludes the arterial lumen. The volcanic eruption may be triggered by the surge in blood pressure associated with intense physical exercise. Ultrafit athlete one minute, ultradead athlete the next.

What’s the moral of the story? Is there any point in looking after yourself? Yes, absolutely. Be an ultra-fit elite athlete every time. You’ll live longer, on average.

What happens after a heart attack?

The key factor is whether your heart attack is only a small one (you live) or massive (you die). After that, it’s just detail. The type you have depends on several factors, including your age, your previous level of physical fitness, which coronary artery is affected, and how quickly and well a collateral circulation develops (the area of the heart affected receives a fresh blood supply from the opening up of previously dormant, small coronary arteries originating from a non-obstructed part of the coronary circulation). Oh, and how well and quickly you are resuscitated, of course. Never forgetting the all-important wildcard, Lady Luck!

Severe chest pain

Classically, the victim of a heart attack complains of chest pain as the area of heart muscle downstream of the arterial blockage cramps up. The pain intensity is often severe and may be described as a diffuse, dull, aching tightness or as a heavy weight on the chest. Rarely is the pain sharp, stabbing or well localised. Unlike angina, it may not be precipitated by exercise, and if you are exerting yourself when the pain first comes on, it doesn’t relieve with rest. The pain may radiate down one or both arms or into the neck and jaw. To make matters more complicated diagnostically, the pain can mimic indigestion, and some people have a heart attack without experiencing much or any chest pain at all (see silent heart attacks).

Associated symptoms

Apart from chest pain, many heart attack victims feel nauseated and vomit. They may notice palpitations, an unpleasant awareness of their heart beating hard in their chest, often rapidly and irregularly. They may feel lightheaded and dizzy if their heart is not beating strongly enough to generate a decent blood pressure. Victims often report feeling a sense of impending doom. This is caused by the effect of industrial quantities of adrenaline, the fight-or-flight hormone for the body’s emergency use only, on the brain. The sense of doom is not an overreaction. Fully 10% of all people who have a heart attack present with cardiac arrest. They’re minding their own business, getting on with their day, when they drop down stone cold dead without warning. Game over. Or maybe not. Does anyone know how to perform bystander CPR?

The silent heart attack

Some heart attacks go unrecognised because the pain is not that severe or it’s blamed on a dodgy kebab, IBS or something else relatively trivial that the victim doesn’t seek medical advice for. Still other heart attack victims have no pain at all. Diabetics with sensory neuropathy (dysfunction of nerves that convey sensation) are more prone to this.

As a related aside, I examined hundreds of routine preoperative ECGs when I was a surgical house officer, a significant number of which exhibited the unmistakable pattern of a previous heart attack that hadn’t been disclosed by the patient in their medical history. When I later quizzed these patients as to when their heart attack had occurred and what had happened to them, they would deny all knowledge.

Heart failure and cardiogenic shock

This is a life-threatening problem and is more common after a Widowmaker event. Cardiac muscle cells die if they lose their blood supply for more than a few minutes. If enough left ventricular muscle mass is lost, it is unable to generate sufficient arterial blood pressure to force a normal cardiac output through all the organs and tissues of the body. This combination of low arterial blood pressure and low cardiac output is called cardiogenic shock. On top of this, the right ventricle hasn’t been perturbed one jot by the events happening on the other side and is still merrily pumping blood through the lungs to the left ventricle. A massive backlog of blood pools in the lungs, leading to fluid leaking into the alveolar air spaces of the lungs. The resulting acute pulmonary oedema is a terrifying ordeal for a patient, who becomes severely breathless. They are literally drowning in their own blood.

Powerful drugs can be administered intravenously in the coronary care unit or the ICU to patients with cardiogenic shock and offer a helping hand to the failing left ventricle while it (hopefully) weathers the storm and gets its act together as a collateral circulation is established. I used them hundreds of times during my career, and although they can’t polish a turd, they undoubtedly saved many lives.

Before we move on from talking about cardiogenic shock, I wanted to clarify what doctors mean when they say that somebody is suffering from shock. It’s a term that is often loosely banded around when a major incident or other tragic event is reported in the news. The victim is said to be ‘in shock’. I’m not certain precisely what reporters mean by this because I’ve never asked one. What I think they mean to say is that the person affected is in a state of high emotional and psychological trauma. That’s not what medical shock is. Shock is defined as life-threatening circulatory failure in which the body’s tissues and vital organs do not receive sufficient blood flow or oxygen, often, but not always, associated with low arterial blood pressure. There are other causes of shock aside from the cardiogenic shock of acute heart failure. Major blood loss or severe dehydration produces hypovolaemic shock; severe systemic infection produces septic shock; an acute allergic reaction produces anaphylactic shock.

Heart Failure

If the Widowmaker does not, in fact, make your nearest and dearest a widow by sending you to meet your maker after succumbing to the acute heart failure of cardiogenic shock, you’re not necessarily out of the woods. Your left ventricle may lose the ability to contract forcefully forevermore, and you end up with chronic heart failure. Sufferers complain of chronic fatigue, poor exercise tolerance, episodes of acute nocturnal breathlessness and swelling of legs, feet and ankles. It’s a serious life-limiting medical condition with about half of all those affected dying within five years. That’s a worse outlook than many cancer diagnoses.

Cardiac arrest

By the simplest definition, cardiac arrest occurs when the heart stops beating. Technically, of course, everyone dies of a cardiac arrest, from the person run over by a bus to the emaciated sufferer of stage four cancer to the centenarian who dies quietly of old age in their bed, asleep one night. It is, after all, how we tend to define death (unless we’re talking about brainstem death). A more useful definition in the context of acute medicine and resuscitation is that a cardiac arrest is the sudden, unexpected collapse of the heart’s mechanical pumping action that is potentially reversible. Thus, when a catastrophic injury, terminal illness or decreptitude reaches its natural end, the stopping of the heart is the result of death. In contrast, during acute resuscitation, cardiac arrest is treated as a remediable condition that may or may not lead to death.

That’s all I’m going to say on the subject of cardiac arrests for this post. It’s a big topic, and I’ll devote the next post to it.

Cardiomyopathy

Before I nip off, I just want to say a brief word about cardiomyopathies. They are a collection of cardiac conditions unrelated to heart attacks and atherosclerotic coronary artery disease that can, however, cause heart failure and cardiac arrest. They are surprisingly common, affecting about 1 in 250 people. There are inherited and acquired forms that come in a variety of flavours, including dilated cardiomyopathy, hypertrophic cardiomyopathy, restrictive cardiomyopathy and arrhythmogenic cardiomyopathy. The core symptoms are generally those of chronic heart failure. Arrhythmogenic cardiomyopathy is the cause of sudden death in some young, healthy individuals playing sport.

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Who's Who and What's What: Inside NHS hospitals

Dr Tony McCluskey — Sat, 16 May 2026 00:00:00 +0000

Other NHS hospital staff (Part 2)

In the last post, we looked at all the different types of nurses who work in NHS hospitals. In this post, we’ll concentrate on the other clinical staff you might run into.

Midwives (aka Madwives)

I didn’t include midwives in the previous post because most midwives today aren’t nurses. Midwives have actually been regulated, independent medical practitioners in their own right since The Midwives Act, 1902. However, at the inception of the NHS in 1948, the nurse-midwife model dominated, in which most midwives first qualified as nurses before specialising in midwifery. Certainly, as a callow trainee anaesthetist, most of the midwives I worked with had previously been nurses. During the course of my career, the model shifted to direct-entry midwifery training programmes. The rationale was that birth is a normal physiological process and that the relationship between an expectant mother and her midwife is not a nurse-patient relationship. Expectant mothers are not patients. It was further argued that a nurse’s knowledge, mindset, and skill set were not optimally suited to managing a labouring woman.

I am going to rashly stick my head above the parapet now and risk incurring the wrath of midwives up and down the country. I quite liked it when the midwives I worked with as a junior anaesthetist were also trained nurses. I do agree that birth is a natural physiological process, and labouring women, perhaps, shouldn’t be viewed as patients needing to be nursed (or doctored). However, in the real world, pregnancy and giving birth are sometimes pathophysiological processes: major haemorrhage from placental abruption or placenta praevia, hypertensive disorders of pregnancy, pre-eclampsia and eclampsia, gestational diabetes, anaemia, DVT and pulmonary embolism, amniotic fluid embolism, sepsis, and so on. Labouring women also request epidurals, a major medical intervention in anyone’s book. Labours obstruct. Unborn babies exhibit fetal distress necessitating emergency caesarean section. There are loads of other reasons why a labouring mother might need a section.

Anaesthetists aren’t involved in the birth of a woman undergoing ‘natural childbirth’. My presence was only demanded if she requested an epidural or if the shit was hitting the fan in any of the ways suggested above, or in ways I neglected to mention. In these latter circumstances, I tended to feel that it was better for the patient (as soon as I became involved, a labouring mother instantly became my patient, whatever designation she held beforehand) if the midwife assisting me had received nurse training. I somewhat regret that this is no longer the case.

There, I’ve said it. Hard hat on and wait for the flak.

More than a bit scary to most junior doctors, and some consultants, midwives actually do an amazing job under tremendous pressure. The shortage of midwives in the UK is even more acute than that of nurses. It is a significant contributory factor to concerns that obstetric units across the UK may be failing to deliver the highest possible standard of care. In the last ten years, at least seven major national enquiries have been launched, three of which are currently ongoing. They have concluded, or will conclude, that maternity care is suboptimal, resulting in avoidable baby and maternal deaths. They have declared, or will declare, that better systems, processes, training, clinical audit and performance review are required to achieve better outcomes. I am sceptical that the conclusions and recommendations of all these enquiries stemming from the ‘lessons learnt’ will ever be successfully implemented without an appropriate injection of monetary resources. From a bloody large syringe!

Radiographers

A large set of biophysical technicians that most of us have encountered at one time or another, radiographers are easily identifiable because they glow in the dark from accumulated exposure to X-rays. In addition to X-ray examinations, they perform CT and MR scans, as well as other imaging investigations, including ultrasonography. They are second only to consultant radiologists in their ability to diagnose from X-rays or scans.

Other Medical Biophysics Technicians

A heterogeneous group, they include laboratory technicians, microbiologists, ECG technicians, echocardiographers and phlebotomists. The first two don’t get out much, so patients seldom encounter them. If an ECG technician introduces themselves and connects a bunch of ECG leads to your chest, the indigestion you thought you were suffering from could well be a heart attack. Echocardiographers perform ultrasound scans on pregnant women to date pregnancies, assess fetal growth and check for fetal abnormalities. They also scan your gallbladder if you’ve been suffering from flatulent dyspepsia or biliary colic, your liver if you’ve turned yellow recently, your kidneys if you’ve noticed blood in your pee, your heart if you’ve been getting increasingly breathless and your ankles have swollen, your breasts if you’ve noticed a lump, and just about every other organ and tissue in your body as required.

Physiotherapists (physios)

These are the people to see when you’re recovering from a hip or knee replacement, have a frozen shoulder that needs defrosting, suffer from chronic back pain, are learning to walk again after a stroke, or need help coping with a host of other neuromusculoskeletal calamities. They make you mobilise whichever bit of you would benefit from a spray of WD40, no matter how agonisingly painful it might be. ‘Cruel to be kind’ is their motto.

Occupational Therapists (OTs)

If you need help performing certain activities of daily living to maintain your functional independence, whether from physical or mental illness, you need the services of an occupational therapist. These activities range from simple things like washing, dressing and cooking to more complex work-related tasks.

Speech and Language Therapists (SALTs)

They provide treatment and support for people with difficulties communicating verbally, eating, drinking and swallowing, often as a result of a stroke. As an ICU consultant, I was very reliant on SALTs to assess whether it was safe to orally feed ventilator-dependent patients and patients with tracheostomies.

Dieticians

Their input is invaluable if you have specific nutritional needs or dietary intolerances. Critically ill patients in the ICU usually meet the criteria for the first group, so I used to see a lot of our hospital dietitian. She always used to pitch up at the end of her working day and would then spend hours assessing every patient, writing reams of dietary advice in the notes. I’m not sure if she had a home to go to because she was often still hard at it long after eight o’clock.

Orthoptists

My younger sister was diagnosed with a lazy eye when she was only four or five. She had to wear an eye patch over her good eye to encourage her lazy eye to do a bit. My brother and I found this most amusing and used to shout words of encouragement at Lazy Eye: ‘Go on, you can do it!’ ‘Try harder!’ ‘Wake up!’

I didn’t realise it at the time, but my sister had seen an orthoptist. Experts in diagnosing and treating squints, eye movement disorders and binocular vision, orthoptists could be described as eye physiotherapists. I think they’re all brilliant, and not just because my sister’s lazy eye became a prodigiously hard grafter after a few sessions with her orthoptist – one of my daughters is one.

Organ transplant coordinators

I couldn’t do their job. As an intensivist, I managed critically ill patients all the time, many of whom ended up dying. Afterwards, I had to speak to the family members. It was stressful and upsetting stuff. Even so, most of the patients I admitted to the ICU survived, and so the good karma outweighed the bad. Now imagine if all your patients died. Every single last one of them. Imagine having to speak to all those deceased patients’ families. Not to tell them you did everything you could to save their loved ones, but to ask them for a few of their organs.

Organ transplant coordinators play an essential role in ensuring that as many people’s lives are saved, or at least radically transformed, by receiving an organ transplant, be it a kidney, a liver, a heart, a pair of lungs, both heart and lungs, whatever. To achieve this goal, they act as intermediaries between the ICU team, the transplant surgical team and the deceased’s family. It’s a delicate task that requires the very best communication skills, empathy, patience and kindness. Organ transplant coordinators also have to be extremely well organised and willing to work day or night, seven days a week.

Sadly, there is an insufficient supply of organs for donation to satisfy the demand from patients dying of kidney failure, heart failure, respiratory failure, liver failure and the rest. The total number of people needing an organ transplant in the UK in 2025 was about 8,000, more than half of whom were waiting for a kidney transplant. Against this backdrop, about 1,400 people received a transplant from a deceased donor in 2024/25 (a 7% decrease on the previous year), and just under 1,000 people received an organ from a living donor (usually a kidney or part of the liver). Meanwhile, hundreds of people on the transplant list die every year waiting for a donor.

An opt-out scheme has existed throughout the UK since 2023 to maximise the availability of organs for transplant. The scheme presumes that everyone consents to the donation of their organs after their death unless they specifically and formally object. In addition, there is an NHS organ donor register, which everyone is encouraged to sign up to, to make it abundantly clear and obvious to your nearest and dearest that you positively would like your organs to be donated in the event of your untimely death. So why the shortfall?

The biggest reason is that only about 1% of everyone who dies does so in circumstances that allow their organs to be donated (such people are usually diagnosed as being brain dead while in a deep unresponsive coma on a mechanical ventilator on the ICU after a severe head injury, brain haemorrhage or other catastrophic acute brain injury. I’ll be discussing brainstem death (BSD) in a later post, so I won’t expand further here. In addition, even under the opt-out law, assent to retrieve organs in these utterly distressing circumstances is still routinely sought from the deceased’s next of kin. If it is not forthcoming, organ retrieval does not proceed. Family members can therefore veto organ donation, and around 40% of all potential organ donations are lost because of this. Crucially, it makes a massive difference if the deceased’s explicit wishes are known (because they have previously registered on the organ donation register or discussed the subject with their family). When they are known, the family refusal rate is only 10%. Where they aren’t, it’s 90%.

So, if you haven’t already, please discuss your views on organ donation with your husband, wife, mistress, partner, or dog. And if you agree with the concept, consider signing up. You can do this easily online at https://www.organdonation.nhs.uk/register-your-decision/donate. If you have the NHS app, you can also record your decision by going to Profile > Personal Details > Health Choices > Organ Donation Decision.

Anaesthesia Associates (previously known as Physician Assistants (Anaesthesia))

I am reliably informed that, like nurse consultants, these do exist. However, they are even rarer and much harder to spot (there were only 186 on the official GMC register as of January 2026). If you do see one, award yourself 100 I-Spy points. ‘But I’m too young to remember the I-Spy series of books published in the 1960s,’ I hear you cry. Well, bully for you. I’ll take my 100 points back.

Anaesthesia Associates (AAs) aren’t anaesthetic nurses. Nor are they ODPs. They have only been around for about twenty years, having been introduced into the NHS as some mad professor’s hair-brained scheme to address a predicted shortfall in medically-trained (proper) anaesthetists. I know I risk upsetting any AAs reading this, but seeing as there are so few of them out there and only about a dozen people and a cockapoo actually read this blog, I’ll take the risk.

What do AAs do? I had to crib this. They administer anaesthetics for straightforward, low-risk cases under the direct supervision of a consultant anaesthetist. One consultant may supervise two AAs simultaneously. I’m not sure how I feel about them. Strike that. I do know how I feel. I think they are the wrong solution to the problem of insufficient numbers of medically-qualified and trained anaesthetists.

Hospital Chaplains

Chaplains are a precious source of strength, comfort and succour for many patients, as well as their friends and relations, when things are not going too well. The final step in the ICU treatment algorithm, if the clinical situation was desperate, was to ask: “Is the patient a no-hoper?” Answer = No: start again from the top and hope it works this time. Answer = Yes: call for the priest.

And it would have been a priest or another Christian minister when I first started practising. Nowadays, it is recognised that patients belong to all faiths or none, and the chaplain on-call rota includes RC priests and Church of England vicars; Methodist, Baptist and Pentecostal ministers; rabbis and imams; religious leaders of the Hindu, Buddhist and Sikh faiths; as well as humanist and secular chaplains. For the same reason, the hospital chapel has given way to the multifaith prayer and meditation room.

I know that some of my colleagues sometimes felt uncomfortable when a critically ill patient’s loved ones sent for the priest or the rabbi or whoever. I think they took the view that the relatives had lost faith in us, the medical carers, and had now turned to God to make the most of a bad job. If not to effect a miracle cure, then at least to ensure an unimpeded passage after death into the heavenly afterlife. I think some of my colleagues also thought that having a priest on the ICU, throwing holy water about the place, might be bad for the morale of other patients on the unit who were conscious and aware of their surroundings.

My own take is that in the game of Life, you need all the help you can get if you find yourself in hospital at death’s door. Chaplains do a great job and can be an immense source of strength and hope to patients and relatives alike.

Two previous patients stand out in my mind for being slightly weird. One professed himself a Jedi Knight, and the other an adherent of the Surakian faith (think planet Vulcan and Mr Spock). The Jedi Knight was sent on his spiritual way with a wave of a lightsaber and the words, ‘May the force be ever with you.’ The Surakian shuffled off his mortal coil with the exhortation to ‘Live long and prosper.’

I’m all for hospital chaplains, but I do draw the line when the doctors themselves get involved in the religious side of their patients’ care. Before I specialised in anaesthesia, I worked as a medical SHO for two years. One of the cardiology consultants was a fervent Christian, either a Baptist or an Evangelical. It was not unusual for him to kneel at the bedside of a patient who wasn’t particularly chipper, make the sign of the cross, and pray for his patient. The look on some of those patients’ faces was a sight to behold.

Ancillary Staff

The unsung heroes of any hospital, porters, electricians, plumbers, catering and domestic staff keep a hospital ticking over. They work incredibly hard for a pittance yet somehow maintain a perpetually cheery disposition. I always tried to make a point of greeting ancillary staff with a wave and a smile whenever our paths crossed.

That’s it for this post. It’s been a bit of a slog trudging through all the different people who work in a hospital. The more perspicacious among you will have noticed that I’ve omitted one of the largest groups, namely hospital managers. Don’t worry, they get a blog post all to themselves and will be making an appearance in due course. However, over the next few posts, I want to discuss a few clinical conditions that are often misunderstood. Stay tuned to find out the difference between a heart attack and a cardiac arrest in the next post.

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Who's Who and What's What: Inside NHS hospitals

Dr Tony McCluskey — Fri, 8 May 2026 00:00:00 +0000

Other NHS hospital staff (Part 1)

As there are so many different types of nurses, I’m only going to talk about them in this post. In the next post, I’ll deal with some of the other groups of clinicians you might encounter during a hospital stay.

Nurses

If doctors are important to the safe and effective running of a hospital, the nurses are downright indispensable. A hospital without nurses is the worst hotel you have ever stayed in – it’s noisy, particularly at night, lacking in privacy and with shared toilet facilities. The air is unpleasantly scented with notes of disinfectant, vomit and poo. The food is average at best, and the place isn’t licensed, so you can forget about a liquid diet. You risk catching this or that horrible infection from one of the other guests. Rather like the Hotel California, the number of guests checking out is significantly lower than the number checking in. Part of the all-inclusive entertainment package may be to witness the dramatic resuscitation of a fellow guest. Will they live? Will they die? Worst-case scenario: the fellow guest is you.

A hospital properly staffed with trained nurses is a place where patients receive the best possible, high-quality, compassionate care. Nurses are by far the largest group of clinical NHS workers, with current figures indicating there are roughly 350,000 of them. When midwives and health visitors are included, they make up 40% of the total NHS workforce. Even so, there are over 25,000 nurse vacancies. This figure would be much higher if it were not for the fact that many vacancies are currently filled by temporary (and expensive) bank or agency staff. Working on the NHS frontline for as long as I did, it was clear to see that hospital wards and specialised departments such as the ICU, the ED and the operating theatres were frequently understaffed. More and more was routinely asked and expected of fewer and fewer nurses.

Unsurprisingly, this kind of treatment knocked the morale of nurses and stressed them out, leading many to abandon ship for less demanding, better-paid jobs with an improved work-life balance. Less pressurised jobs that didn’t require you to regularly make life-and-death decisions. Jobs where you weren’t constantly dealing with suffering, dying and death. Jobs where a mistake didn’t lead to the death of one of your clients or customers. Jobs where you weren’t routinely verbally abused or physically assaulted.

As a result, another perennial feature of hospital life throughout my career was the relentless succession of recruitment campaigns run by hospital managers to plug service gaps. These campaigns often involved managers touring the world in search of recruits from so-called third-world countries in the absence of willing home-grown candidates. The reasons for this shortage are not hard to find. Apart from preferring better-paid jobs with less responsibility and pressure, people with a vocation to become nurses are put off by the tuition fees paid by university students in the UK. Their average accumulated student debt is about £50,000 by the time they have qualified. Crazy! What’s more, no matter how successful these recruitment drives might have been, the influx of newbies entering by the hospital front door was often matched or even exceeded by the efflux leaving by the back door.

The average (median) gross income for a full-time employee in the UK today is about £40,000. A newly qualified staff nurse, after three years of university study and hospital training (and a £50k student debt), earns £32,000. A newly qualified ward sister (or charge nurse) with years of experience under their belt and tons of responsibility just about makes that average income figure. And these are the payments in the NHS. The situation for nurses in the social care sector is far worse.

Rant over, let’s get on with it, shall we? There are about three nurses for every doctor working in NHS hospitals. They come in a dazzing array of flavours: ward nurses, theatre nurses, anaesthetic nurses, recovery nurses, ED nurses, ICU nurses, coronary care unit nurses, outpatient clinic nurses; matrons, sisters, charge nurses (male sisters), staff nurses, health care assistants (HCAs, previously known as auxillary nurses), student nurses; nurse practitioners, nurse consultants, nurse specialists, preoperative assessment nurses – phew! The list goes on. Even so, as we have seen, there are nowhere near enough of them, and the UK is heavily reliant on importing qualified nurses from other countries to help make up the shortfall.

The job description of a hospital nurse is enough to put off even the most ardent budding recruit to the caring profession. At the top of the list, nurses nurse. They look after the basic care needs of their vulnerable charges who, through reasons of age, infirmity and illness, are incapable of looking after themselves. Nurses ensure their patients are clean, warm, comfortable and safe. They toilet them. They serve patients food or feed them when they are unable to feed themselves. They clear up after their patients if they vomit or are incontinent. They closely monitor their patients’ clinical observations and are trained to recognise when a situation requires immediate assessment by a doctor. They provide social and physical contact for patients. They provide reassurance and comfort when patients are distressed. They dispense prescribed drugs. They put up intravenous fluids. They resuscitate patients after cardiac arrest. They communicate with distressed and befuddled friends and relatives, often relaying in more comprehensible language the bad news that the doctors have just told them. They comfort family members during periods of great angst and grief. Throughout all this, nurses maintain their patients’ dignity.

My first book, Vocation, asks whether I had a vocation to become a doctor. While the jury may still be out deciding that one, there is absolutely no doubt in my mind that you cannot be a good nurse without a vocation to the profession.

Another key role of hospital nurses is to guide hapless junior doctors and to step in whenever they might be in danger of doing something stupid (a frequent occurrence) – or of not doing something eminently sensible (an even more frequent occurrence). A ward sister or experienced staff nurse is like a battle-hardened sergeant major to a newly commissioned 2nd lieutenant (house officer) fresh out of Sandhurst (medical school), who doesn’t know their arse from their elbow or one end of the NHS frontline from the other. The best advice you can give a newly qualified doctor is to always listen to the nurses and act accordingly. This is particularly true if they tell you a patient isn’t quite right, even though they can’t put their finger on what it is. Call for backup PDQ and do an immediate clinical assessment. The chances are the patient is heading towards a cardiac arrest if you don’t identify the problem soon and sort it out.

There is a bewildering variety of specialised tasks that nurses undertake in hospitals aside from the common or garden ward nurse’s traditional role of caring for patients on general medical and surgical wards. The following list is not exhaustive. Apologies in advance to all those nurses reading this whose specialist skills I have not included.

Critical Care or Intensive Care Unit (ICU) nurses

I worked very closely with ICU nurses throughout my career. They possess a unique set of advanced knowledge and skills that are essential to safely manage their ventilator-dependent, critically ill patients with multiple organ failure. ICU nurses have to be highly trained because the doctors are not omnipresent on the unit – they’re often busy assessing or stabilising other patients in the hospital, attending meetings, engaged in interhospital transfers of critically ill patients, and so on. ICU nurses, therefore, have considerable autonomy to take independent clinical decisions, alter ventilator settings, administer powerful drugs on their own initiative, extubate patients (remove their tracheostomy breathing tubes), and perform myriad other interventions. If you are unlucky enough to be at death’s door on a mechanical ventilator in your local ICU, take heart from knowing that you will have your very own ICU nurse to look after you, and only you (the nurse-patient ratio is generally 1:1).

ED (Emergency Department) or ER (Emergency Room) nurses

Probably the most stressed group of nurses in the hospital because most UK Emergency Departments are tremendously under-resourced for the number of patients they treat. Key targets for patients to be seen within four hours of arrival and to be definitively dealt with within twelve hours are routinely missed by such a wide margin that they are almost meaningless. The national disgrace that is corridor care is here to stay for the foreseeable future. It is little wonder that the morale of so many ED nurses is suffering. Calm and organised in a crisis, they are particularly adept at resuscitating patients in cardiac arrest or in peri-arrest situations.

Anaesthetic nurses

Unlike nurse anesthesiologists in the USA, anaesthetic nurses in the UK do not administer anaesthetics themselves (although some of the more experienced ones I worked with over the years probably could have managed a routine general anaesthetic solo). Rather, they assist an anaesthetist in the anaesthetic room and operating theatre. A good anaesthetic nurse is indispensable to the safe conduct of anaesthesia, equally as important as the anaesthetist. This is particularly true in an emergency situation when the shit is hitting the fan.

When I first started practising anaesthesia, I was generally assisted by anaesthetic nurses. However, over the years, more and more of the newer Operating Department Practitioners (ODPs) came on stream, and these now make up the majority of newly-qualified anaesthetic assistants. They aren’t nurses, but like nurses, ODPs must study at university for three years to earn a BSc degree. If you have been reading my books, you will have noticed that I sometimes mention an anaesthetic nurse helping me, whilst at other times it’s an ODP. Now you know why.

Recovery nurses

The happy, smiling face you see after waking up from your anaesthetic is likely to belong to your recovery nurse. If the face is scowling and looks a tad pissed off, it’s probably your anaesthetist’s. Recovery nurses are another bunch of highly trained individuals. It’s their job to manage your airway and breathing while you’re still under – your anaesthetist may well have buggered off back into theatre to start the next case. They will remove your laryngeal mask airway or tracheal tube when it is safe to do so, administer morphine and other powerful analgesic drugs via intravenous injection, ditto anti-emetic drugs if you’re puking up, and generally look after you. It is they who will decide when it’s safe for you to be discharged back to the ward or when to call the anaesthetist back to reassess you if they have concerns.

Recovery nurses are routinely used and abused by anaesthetists, particularly those like me who were also intensivists. Whenever the ICU was full (which was often), I would canoodle up to the nurse in charge of theatre recovery and beg him or her to let me park my overdose or septic patient in the corner ‘just until the morning when I’ll have an empty bed.’ Although the skillset of a recovery nurse does overlap a lot with that of an ICU nurse, managing a critically ill, ventilator-dependent patient in recovery was an imposition and far from ideal. Such requests often led to recovery nurses being phoned at home on their days (and nights) off to come into the hospital and look after my patient. Sometimes a recovery nurse who had been on duty since eight o’clock that morning would volunteer to stay overnight as well, because no one else was available. I never ceased to be amazed by the forbearance of my recovery nurse colleagues, who never bore a grudge and still seemed to quite like me.

Preassessment nurses

Another set of nurses who work closely with anaesthetists and who are worth their weight in gold if they’re any good (which they nearly all are) are the preassessment (short for preoperative assessment) nurses. Back in the day, when I was a surgical house officer and later a junior anaesthetist, patients scheduled to undergo elective surgery usually arrived in hospital without their general health status having been properly assessed beforehand. Yes, they’d seen their consultant surgeon in the outpatient clinic and shown them their hernia or piles or whatever, of course. However, surgeons are about as much use as a chocolate teapot when it comes to preoperative assessment. What your average surgeon knows about heart disease, hypertension, respiratory disease, diabetes, and all the rest you could write on the back of a fag packet. So, it wasn’t unusual for patients to be admitted to hospital for their operations, only to be sent straight back home again because their surgeon hadn’t noticed that their blood pressure was so high, the top of their head was in danger of blowing clean off. Or that their blood was sweeter than your average can of Coke. Or that the recurrent chest pain they had been complaining of for the past few months wasn’t simple indigestion but an impending heart attack.

All that nonsense has changed. Now, as soon as a patient is listed for surgery, they’re booked into the preassessment clinic, where a nurse specialist goes through all their health-related issues with a fine-tooth comb. Blood is taken for routine screening. An ECG, chest X-ray, and any other investigations indicated are ordered and reviewed before surgery. Patients with severe hypertension or poorly controlled diabetes are referred back to their GPs to have it sorted, and their operations are postponed. A patient with recurrent cardiac chest pain (unstable angina) is given an urgent appointment for the cardiology clinic. Other issues are flagged for discussion with the relevant anaesthetist to plan next steps. As a result, cancellations on the day of surgery due to a patient not being medically fit for their procedure are rare. It’s one area, at least, where the NHS is doing quite well.

Theatre nurses

The two main types of nurses working in the operating theatre (excluding anaesthetic nurses) are scrub nurses and circulating nurses. The primary difference is their relationship to the sterile surgical field. The scrub nurse is inside and so undergoes the same full scrub as the operating surgeon, whom they directly assist. The circulating nurse is outside, and their job is to open sterile packages of instruments, pass on sutures, swabs, etc, and fetch additional kit as required. The scrub nurse and circulating nurse, between them, are responsible for ensuring that the all-important swab count is undertaken at the end of surgery and, crucially, is correct. Leaving a swab inside a patient is considered poor form. It is likely to lead to a Serious Incident investigation, a complaint from the disaffected patient and a public flogging for all concerned.

Paediatric/neonatal/SCBU nurses

Considering anyone over the age of sixteen to be geriatric, this group of nurses look after children, infants (children under one), neonates (infants under twenty-eight days old) and premature babies (on the Special Care Baby unit, SCBU). I take my hat off to them and to the paediatricians they work alongside, for what they do. Quite early into my clinical training as a medical student, I learnt that I couldn’t.

Advanced Nurse Practitioners (ANPs)

These are a very highly qualified group of nurses (generally with a Master’s degree) who assess, diagnose and treat patients, and prescribe them certain medications. An ANP might see you in the outpatient clinic rather than the consultant or a junior doctor for the routine review of your hypertension, COPD, asthma or diabetes. An ANP might perform a minor operative procedure on you, such as the excision of minor lumps and bumps or a back injection for chronic pain.

An ANP with whom I worked in the ICU for many years was absolutely brilliant. He knew more about assessing and treating critically ill patients than most junior doctors. I always loved it when he was on call with me because it meant I would rarely be dragged out of my pit in the middle of the night. He would be seeing to everything. Marvellous.

Nurse consultants

These were introduced into the NHS in 1999. I never met one and consequently have no idea what they do. Call me a conspiracy theorist, but I think the role was manufactured simply to make it look like the NHS had more consultants than it does. However important their role may be, there are only about 1,000 of them working across the NHS, making up less than half of one per cent of the entire nursing workforce.

Infection control nurses, aka infection control police

I always used to dive for cover whenever I saw one of these heading my way. I knew I would be infringing at least one infection control rule, meaning it was almost certain I would pass on contagion to every patient I met. If I hadn’t forgotten to take my watch off, my sleeves wouldn’t be rolled up. Or my tie would be wafting lazily in the breeze. Or there was an unsightly stain on my scrubs, the nature of which didn’t bear thinking about. I was at least confident it couldn’t be my unhygienic white coat, because the infection control police had banished those years ago, and I wouldn’t be wearing one. Do you know, there are apparently more germs on your average white coat than there are in your average dog turd. I suppose I should have washed mine more often than once a year.

Educational tutor nurses

Those who can, do. Those who can’t, teach. Those who can’t teach, tutor. Enough said.

Miscellaneous nurses

If you’re a nurse and I haven’t mentioned you yet, you’ll be less than chuffed to note that I’ve included you in the miscellaneous group (or worse, forgotten all about you entirely). I’m sorry if you feel like you’ve been lined up in the school playground, waiting to be picked by the captains for a place on the team, only to find yourself the last man or woman standing.

One reason you’re miscellaneous is that I don’t know much about what you do, having never really worked with you much during my career. The group includes psychiatric nurses, rehabilitation nurses, palliative care nurses and oncology (cancer care) nurses. I’m sure you do a great job and deserve more recognition than I’ve afforded you. Soz.

Summary

Nurses do a superb job. They are fantastic. It must be true because I married one.

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Who's Who and What's What: Inside NHS hospitals

Dr Tony McCluskey — Thu, 23 Apr 2026 00:00:00 +0000

Doctors (Part 2)

Surgeons

There are more surgical specialties than you can shake a scalpel at. In order of decreasing IQ, they include:

Neurosurgeons, aka brain surgeons

Every young and ambitious schoolboy and schoolgirl dreams of becoming a neurosurgeon. It kind of makes sense that this group of doctors is the most intelligent, at least among the surgeons. They work on other people’s brains day in, day out, so it stands to reason they get to know what makes a really good brain tick and therefore how best to use their own. Plus, I wouldn’t be surprised if neurosurgeons didn’t occasionally augment their own processing capacity by surreptitiously slicing off the best bits of some of their patients’ brains and surgically splicing them onto their own.

Ophthalmologists, aka eye doctors

I’ve put this bunch in second place because it takes real intelligence (intelligence that I was sadly lacking in) to realise right at the very beginning of your medical training that ophthalmology consultants rarely, if ever, get called back into the hospital out-of-hours and have a lucrative private practice, to boot. They also have the least to learn. The eye is very small, after all, with only so many bits and pieces inside it. Ophthalmologists only know how to do three operations: removal of cataract, trabeculectomy (an operation for glaucoma, high blood pressure of the eye; you can go blind if it’s left untreated) and surgical extraction of a fly trapped underneath your eyelid.

Urologists, aka willy doctors

In a well-deserved third place, urologists don’t get called back into the hospital much either. They don’t just operate on willies, though. Bladders, urethras, ureters, kidneys and prostates (note, not prostrates) are all included in their remit. A friendly bunch, some of my favourite surgeons were urologists.

Otolaryngologists, aka ear, nose and throat (ENT) doctors

They operate almost exclusively on perpetually snotty-nosed kids with permanent sore throats or deaf kids with smelly pus coming out of their ears.

Cardiothoracic surgeons, aka heart doctors

The epitome of NHS heroes, this lot save lives on a daily basis. They would be higher up my list if it weren’t for the fact that they are often called back into the hospital at all hours to perform heart and lung transplants. Sharing the glory with them are the kidney and liver transplant surgeons.

General surgeons

When I was training, being a general surgeon was really a thing. They operated on gullets, stomachs, small bowels, colons, rectums, livers, pancreases, gallbladders, thyroids, arteries and breasts. They whipped off lumps and bumps from just about anywhere. They became extinct somewhere along the line, I’m not sure when exactly, to be replaced by a family of subspecialists including upper GI surgeons, colorectal surgeons, hepatobiliary surgeons, vascular surgeons and breast surgeons. A good thing, too, I suppose, because while being a jack of all trades and a master of none might be satisfying for a surgeon, you, the patient, would probably prefer to be operated on by somebody who does tons of whatever it is you’re under the knife for.

Obstetricians and gynaecologists, aka doctors dealing with women’s bits.

Very womb-centric and so only relevant to roughly half the population, these surgeons divide their time between the delivery suite and the operating theatre. In the former, they facilitate the safe arrival of new babies into the world by performing forceps deliveries and Caesarean sections. In the latter, they essentially do the opposite by performing hysterectomies and laparoscopic sterilisations.

Maxillofacial surgeons, aka max-fax.

Gluttons for punishment, these surgeons have to be doubly-qualified in medicine and dentistry, which means that by the time they’ve completed all their training, it’s nearly time to retire. I only ever anesthetised their patients when they were having their wisdom teeth extracted, so I rarely got to see them practising their obviously prodigious surgical talents on bigger stuff. If you inadvertently refer to them as dentists, prepare to have your lights punched out.

Plastic surgeons, aka cosmetic surgeons.

They make loads of dosh doing private nose jobs, face lifts and Botox injections for the rich and famous. To be fair, they also do a grand job in their NHS practice of reconstructing and repairing the victims of severe burn injuries and trauma. I should really have put them much higher up the list. I didn’t because I hated them all the years I was an anaesthetic registrar. It is a resident plastic surgeon’s job to re-implant fingers that have been accidentally torn off (it happens a lot more often than you might think). Sadly, it was my job to anaesthetise those patients. Watching somebody painstakingly operating on blood vessels and nerves I could barely see (the surgeon wore loupes, operating magnifying glasses) for hour after hour after hour throughout the entire night makes watching paint dry and grass grow palpitatingly exciting in comparison.

Orthopaedic surgeons, aka orthopods, aka bone doctors.

Although some of my best friends were, and remain, orthopaedic surgeons, all my fellow anaesthetists will agree with me that they rightly take their place at the foot of the surgical IQ league table. Orthopods are basically surgically-qualified DIYers. Forget the loupes, the small retractors, the delicate 8-0 sutures. Just give them a power drill and a hammer. No, not that one – the big one. Crash, bang, wallop! Sorted. Only an orthopod would declare in the middle of an operation that wasn’t going so well, ‘This hammer doesn’t work, get me another one.’

Like general surgeons, orthopaedic surgeons have sub-specialised. Now we have knee surgeons and hip surgeons; foot surgeons and hand surgeons; shoulder surgeons and back surgeons. The back surgeons have specialised even further into neck surgeons and lower back surgeons. If you’re ever involved in a serious road traffic collision and sustain multiple injuries, you can rest easy in your anaesthetised slumber while an entire regiment of orthopaedic surgeons put you back together again. In the fullness of time, I fully expect there to be different orthopaedic surgeons specialising in the thumb, ring finger and little pinkie.

The Service Specialties, aka ‘I didn’t know they were proper doctors’ doctors.

The hallmark of these specialists, apart from the fact that people often don’t realise, or care, that they are medically qualified, is that their patients don’t officially belong to them but are instead registered under another consultant’s name, usually a physician or surgeon.

Anaesthetists, aka sleep doctors.

The claim to fame of this group of doctors, apart from having a name nobody can spell correctly, is that they are the largest of all the medical specialties. Anaesthetists can be found in the operating theatre giving anaesthetics, on ICUs directing the medical management of critically ill patients, on the delivery suite providing labouring women with pain-relieving epidurals, running chronic pain clinics, leading cardiac arrest and other emergency resuscitation teams, as well as teaching other doctors, nurses and paramedics the principles of resuscitation. There is almost nowhere in a hospital where you won’t find an anaesthetist, and fully 70% of all hospital inpatients will encounter an anaesthetist at some point during their admission.

Most people have only the vaguest idea about what an anaesthetist does. What they do know has usually been acquired by watching TV medical dramas. An intravenous injection of a sleep draught and a whiff of gas to send the patient off, an injection of antidote and turn the gas off again to wake the patient up at the end of surgery, with nothing much else to do in between time except complete The Telegraph crossword. Surveys regularly show that nearly half of the general population does not know that anaesthetists are medically qualified. A patient once asked me what it was like to be an anaesthetist. I was delighted she was so interested and enthusiastically gave her chapter and verse about what a fascinating and professionally challenging job it was. My bubble burst when she said, ‘I think that’s something my son would like to do. He didn’t get the grades to get into university, so becoming an anaesthetist would suit him down to the ground. Can you study it at night school?’

Radiologists, aka X-ray doctors.

Never confuse the term radiologist with radiographer if you are in the X-ray department for an X-ray or scan (ultrasound, CT, MR, PET, radionuclide investigation, etc). Radiologists are doctors. Radiographers are highly qualified medical technicians, but they are not medically qualified. Radiologists, like anaesthetists, are a trifle miffed when their patients don’t realise this, particularly if they ask, ‘When will I be seeing a doctor?’

Radiologists used to spend pretty much all their time closeted in their cubbyhole, windowless offices, reporting on said X-rays and scans. However, they have reinvented themselves during my working lifetime as interventional medical practitioners, performing complex, invasive diagnostic investigations and therapeutic procedures such as coronary and cerebral angiography, balloon angioplasty, coronary stent insertion, biliary stent insertion and percutaneous nephrostomy, to name but a few.

Pathologists, aka lab doctors.

This hodgepodge of doctors can be found lurking in the mysterious clinical sciences buildings, within which the hospital mortuary is usually housed. They include chemical pathologists, microbiologists, haematologists and histopathologists.

Chemical pathologists run hospital biochemistry laboratories that analyse samples of body fluids, such as blood and urine. They advise physicians and surgeons regarding the diagnosis and treatment of patients with abnormal test results.

Microbiologists run the hospital’s microbiology and virology laboratories, which analyse samples of body fluids and tissues for bacteria and viruses to diagnose the cause of infections and determine which antibiotics and antiviral agents the organisms are sensitive to.

Haematologists run hospital haematology laboratories, the blood bank (which provides blood and blood products such as platelets, clotting factors, plasma and suspended white blood cells), and the anticoagulation clinic. Their job is to diagnose and treat disorders of the blood and bone marrow such as anaemia, haemophilia, leukaemia and lymphoma. Unlike chemical pathologists and microbiologists, who don’t get out much, haematologists like to escape the confines of their laboratories whenever they can to assess actual patients on the wards and in outpatient clinics.

Histopathologists are the doctors most people think of as pathologists. As well as examining biopsy tissue samples under the microscope for evidence of disease such as cancer, they examine whole patients, usually dead ones, in the hospital mortuary. Forensic pathology, the criminal investigation branch of histopathology, has become sexy in recent years thanks to TV programmes such as Silent Witness, Waking the Dead, and the CSI franchise, and many universities now offer BSc degree courses on criminology and forensic science. Aspiring forensic pathologists should be warned, however, that the only route to realising their dream in the UK is to spend five or six years studying at medical school, followed by ten years training as a junior doctor before finally becoming a consultant. Choosing a career as a histopathologist is a good choice if your communication skills and bedside manner are lacking. Practitioners of the dark art also have the enviable reputation of never receiving complaints from their patients or being sued by them.

Occupational Health doctors, aka Sick Leave police.

Their patients are the staff of the company or organisation they work for. Fortunately, I didn’t have much to do with ours, apart from when I had three months off work with back trouble. I wasn’t swinging the lead, either, because I ended up having a two-level discectomy and lumbar decompression/stabilisation. I suspect I would have seen a lot more of our occupational health doc towards the end of my career had I not diagnosed myself with burnout and decided to take early retirement.

Hospital Doctor Grades

If you thought the nomenclature of hospital specialists was bad enough, the grading system used to denote the seniority and status of hospital doctors is even more arcane and confusing. Terms abound, including house officers, senior house officers (SHOs), registrars, senior registrars (SRs), specialist registrars (SpRs), specialty registrars (StRs), consultants, staff grades, specialist and associate specialists (SAS doctors), specialty trainees, foundation doctors, junior doctors, trainees, core trainees, residents, locally employed doctors (LEDs) – the list is endless. Phew!

Consultants

Consultants sit at the apex of the medical pyramid. I speak from experience when I say it’s not easy to become one. First, you have to get into medical school. That’s far from a walk in the park when approaching 30,000 budding doctors apply each year for fewer than 10,000 places, never forgetting that to join the ranks of those 30,000 hopefuls, you should be expecting to achieve a minimum of three A grades at A Level, with top-tier universities also demanding at least one A* grade. Five or six years of hard slog later, you graduate with your medical degree, which is only marginally more valuable than the parchment it’s printed on as a marker of how ready you are to assume the mantle of junior doctor (oops, I mean resident doctor – see later).

If you thought it was tough thus far, the really hard work only now begins in earnest, as over the next ten years, you work long and stressful hours learning how to be a doctor, making life and death decisions regularly along the way, while simultaneously applying for, and succeeding in getting, the next job up the greasy pole. In addition, there’s studying for postgraduate examinations with a broader curriculum than most university degrees in the spare time you don’t have, paying for them, and passing them (the pass rate for most postgraduate exams is less than 50%). Shoe-horned in between all that is your private life. Work-life balance? Forget it.

Once you’ve been appointed as a hospital consultant, you’ve made it. Well done, you! Time to buy that new set of golf clubs and work out the quickest route to the private hospital where you’ll now be spending most of your time (only kidding).

I mentioned it briefly in the last blog, but it seems a good idea to clarify why some hospital doctors are referred to as ‘mister’ rather than ‘doctor’. Many people are confused on this point or simply assume that all consultants are misters. Here’s the reason.

Medical students work their bollocks off to gain the coveted title of ‘doctor’. They’re not proper doctors in the academic sense, of course. The only route to becoming a ‘real’ doctor is to undertake a PhD at university (a doctorate of philosophy degree). For example, my chemistry teacher at secondary school, Dr Slater, was a real doctor. Despite the exacting entry requirements and the long years of study, the qualification you come out of medical school with is a bog-standard Bachelor of Science degree. Your title of doctor is, therefore, honorific.

You would have thought that after sacrificing so much and working so tirelessly to be awarded the title of doctor, the last thing you would do is immediately set forth on a course of study, the end result of which would be the removal of that title. However, that is precisely what happens with surgeons. Once they pass their fellowship of the Royal College of Surgeons examination, they revert to being called plain old Mr again (or Mrs or Miss). In effect, they spend five or six years in medical school to become doctors, and then spend the next five or six years relinquishing the title. Work that one out.

Professors

A special type of hospital consultant is the professor. Starting off as a common or garden doctor, you generally get to become a professor by conducting scientific research as a university senior lecturer into a particular area of clinical interest. Over years of intense academic study, your focus of enquiry intensifies and narrows, and you come to know more and more about less and less until finally, knowing absolutely all there is to know about absolutely nothing, you are made a professor. One anaesthesia professor I worked with certainly fitted the bill. He might have been a whizz with a test tube in the lab, but he was a bloody liability in the anaesthetic room. Even as a lowly registrar, I always used to try to persuade him to catch up on his university admin in the coffee room while I got on with the job of safely looking after his patients before he killed them.

Nurse consultants

Another special type of hospital consultant is a nurse and not a doctor. Confused? So am I.

Junior doctors, residents and SAS doctors

There is a bewildering array of hospital doctors who are not consultants. Some of them are training to become consultants (trainees), others are no longer in training and work in permanent posts at other grades. It will give you a headache trying to make sense of who’s who. It’s given me a headache just thinking about what I need to say. However, I will do my best to make some sense of it.

The Firm

Back in the day, junior hospital doctors worked together in a team called ‘The Firm’. A firm comprised, in order of decreasing seniority, a consultant, senior registrar (SR), registrar, senior house officer (SHO) and house officer. Not all firms had all five ranks, though they all had a consultant and a house officer. You saw patients as a team. You had sleepless nights as a team. You lost patients as a team. You saved patients’ lives against all the odds as a team. You stressed out as a team. You consoled and supported each other when the going got tough, as a team. A firm provided a structured mentorship and apprenticeship. Being a member of a firm was key to surviving and thriving as a junior doctor. Your firm was almost like an adoptive family.

The system worked really well. Sadly, Health Secretaries, NHS managers and senior medical academics adopted a ‘If it ain’t broke, damn well fix it’ philosophy. A system which served doctors and patients well was chopped and changed so much over the years since I trained that it’s now almost unrecognisable. Here’s what we have now:

Foundation Year 1 trainees (FY1)

Basically, house officers in their first year of medical practice.

Foundation Year 2 trainees (FY2)

These would have been first-year SHOs in my day. All newly qualified doctors must follow a structured training curriculum during their two foundation years. They must demonstrate core competencies and be signed off before they are allowed to continue their medical training.

Core Trainees

After foundation training, doctors enter a core training programme to gain deeper experience in a specific field of medicine or surgery for two or three years. Such doctors are designated CT1, CT2 and CT3. FY2 doctors and core trainees together constitute old-fashioned SHOs.

Specialty Registrars (ST3-ST8)

The registrars and senior registrars (SRs) I grew up with were first amalgamated into a unified grade designated as specialist registrars (SpR). Don’t ask me why. I’m damned if I can remember, and I can’t be arsed to look it up. Some time later, the powers that be decided another tweak was needed, and SpRs became StRs (I think this stood for specialist training registrar, but once again, I haven’t the foggiest what the point of the rebranding was. Finally, we arrive at where we are now with the new, super-improved specialty registrar grade (ST1, ST2, etc, the number indicates years of seniority).

SAS doctors (Specialists, Associate Specialists)

This group of doctors is not in training. The only difference between the two designations is historical. SAS posts are taken up by individuals who, for one reason or another, do not intend to become consultants. Some of the best anaesthetists I worked with were SAS doctors.

Locally Employed Doctors (LEDs)

These doctors are also not in training. The posts are often temporary stepping stones to a training post or SAS position.

Junior doctors versus resident doctors

I never minded being called a junior doctor ten years into my training and fully sixteen years after first arriving at medical school, and I don’t recall it ever being an issue with any of my colleagues. However, times change and referring to doctors with years of experience under their belt was deemed (by the BMA, the British Medical Association, the doctors’ trade union) to be demeaning, giving the impression to the general public that junior doctors were somehow inferior and underqualified. As a result of a rebranding exercise, 50,000 junior doctors became resident doctors on 18 September 2024. On a point of order, SAS doctors were never junior doctors and are not residents.

Of course, patients don’t give a toss what moniker a doctor goes by. All they care about is whether their doctor is safe, knowledgeable, and can make them better. None of it would matter if The Firm were still there to safely manage patients and serve as both an apprenticeship-teaching model and a mutual support mechanism for the doctors. Sadly, though, not only have the titles on the hospital name badges changed, but so too has the operation of The Firm. There are too few resident doctors on duty at any one time to look after the number of acutely ill inpatients on the wards, so The Firm cannot function as it once did when I was roaming the wards.

There are several reasons for this. Back in the day, many hospital inpatients were either convalescing or were only moderately unwell. Nowadays, you virtually have to be at death’s door to merit a scarce hospital bed. Demand for hospital beds has increased almost exponentially over the years, while the availability of resident doctors has decreased following the implementation of the European Working Time Directive (EWTD). The upshot is that The Firm is a luxury the NHS can no longer afford. Instead, disparate groups of residents are thrown together almost at random to cover hospitals at night and over weekends. There is no sense of team. No mutual support mechanism. No sense of belonging. I know I sound like an old fart – correction, I am an old fart – but that’s my view, and I’m sticking to it.

Medical Students

The chances are that if you’re a hospital inpatient or outpatient, you will come across medical students eager to find something interesting in your medical history or, even better, on physical examination. As an aside, there’s an old saying known only to doctors: never be an interesting patient. If a doctor ever tells you you’re an interesting case, it’s time to make your last will and testament, if you haven’t already. You’ve either got an incredibly rare syndrome, or they haven’t a clue what’s wrong with you, despite you undergoing every test in the book. Whichever it is, the condition is invariably fatal.

Medical students are a fascinating bunch. They go through five or six years at medical school, being taught a load of stuff that may be of academic interest but doesn’t really prepare them for day one on the wards as an actual doctor. That was true for me forty-odd years ago, and I’m sure it’s even truer today. They often hunt their unsuspecting prey in packs of up to ten, taking turns to poke and prod you. It pays to clench all your sphincters tightly when the medical students are in town.

Third-year medical students are more afraid of you than you are of them, but by final year, the tables have turned. The need to examine every possible pathology in preparation for Finals supersedes all other considerations, and even if you are only visiting your Great Aunt Maud, be prepared to find yourself on the receiving end of a finger up your arse, examining your prostate gland, or your breasts being palpated in the optimistic hunt for a hitherto undiagnosed malignancy.

After qualification, the tables turn again as house officers are terrified of every patient under their care now that it’s their personal responsibility to ensure you don’t peg it.

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Who's Who and What's What: Inside NHS hospitals

Dr Tony McCluskey — Sat, 18 Apr 2026 00:00:00 +0000

A whole bunch of people work in NHS hospitals: doctors, nurses, physiotherapists, occupational therapists, radiographers, phlebotomists, cardiology and respiratory technicians, cleaners, porters and hospital managers. I debated whether to include the managers on my list. Do they do anything that could reasonably be described as work? I decided to include them in the end for completeness. They do, after all, outnumber all the other groups put together. (That statement may not be strictly accurate, but it often feels that way.)

As a patient or hospital visitor, it used to be fairly easy to tell who was who by what they were wearing. Male consultant doctors would be immaculately attired in a tailored three-piece suit, with shiny black shoes and a Rolex wristwatch. Female consultants would be wearing a smart dress or skirt, kitten heels, and tights or stockings. Junior doctors would be kitted out in something similar to their more senior colleagues, albeit less expensively, with the addition of that universally recognised sartorial totem of junior doctors the world over – the hallowed white coat.

When I first started training, nurses all wore a standard uniform, which had changed relatively little over the years. Their smart yet functional dresses were colour-coded to indicate their rank as matron, sister, staff nurse, student nurse or healthcare assistant. Nurses wore a cap, that instantly recognisable symbol of the caring profession, first introduced by Florence Nightingale. Members of all the other groups also wore characteristic uniforms, except for the managers, who would compete with the doctors for the accolade of most fashionable man or woman about town.

Nowadays, it’s Mission Impossible to work out who’s who solely from their appearance. Pretty much everybody has been forced to ditch what they used to wear by the Infection Control Police and dress in theatre scrubs instead. Is the person standing before you the consultant surgeon who’s going to be operating on your gallbladder this afternoon or the plumber who’s on the ward to unblock the ward toilet?

A cross between pyjamas and martial arts kit, theatre scrubs give the appearance that the person wearing them overslept, was in a rush and couldn’t be arsed to get changed for work. Or that the wearer is about to karate-chop their patient back into good health. When I say everybody working in your local hospital has to wear theatre scrubs, I naturally do not include hospital managers. They have retained the right to wear smart, professional-looking clothing. Conspiracy theorists would claim that the scrubs-for-all policy has nothing to do with infection control and everything to do with keeping doctors, nurses and all the other minions in their place.

Doctors (Part 1)

I’ve placed doctors at the top of the pecking order in my Who’s Who list, not only because I was one, but also because, as an erstwhile and perspicacious consultant colleague of mine often pointed out to our managers (it will come as no surprise that it was Ross Logan from my books), a hospital without doctors is a nursing home.

Hospital doctors can be broadly divided into three groups: physicians, surgeons and service providers. In this post, I’ll be talking mainly about the physicians. You’ll have to wait for the next exciting installment to find out what I have to say about the surgeons and service providers.

The cleverest doctors become physicians. It is sometimes said that physicians know everything but do nothing. This is a bit harsh, but there is a grain of truth in the old saying. You do have to be well-endowed with cortical neurones to remember the 1001 symptoms and signs of Rocky Mountain spotted fever or the almost limitless number of potential interactions between the ten different drugs a typical patient might be taking. But what’s the point when most medical diseases are relentlessly progressive, can’t be cured, and will end up killing you anyway?

Not so clever doctors become surgeons. It is sometimes said that surgeons know nothing but do everything. Well, how hard can it be to whip out someone’s inflamed appendix or cobble together your granny’s broken hip with a hammer, a few screws and a metal rod? When a trainee surgeon passes all their exams to become a fellow of the Royal College of Surgeons, they relinquish their title of ‘Doctor’ and revert to being plain old Mr, Mrs or Miss, again. It’s got something to do with bygone times when only prospective physicians went to university to become learned gentlemen. In contrast, any Tom, Dick or Harry could hack off someone’s gammy leg or drain a putrid boil poking out of someone’s rectum. Most surgeons back in the day were barbers, carpenters or butchers by trade. Not much has changed, really.

Service provider doctors are a group that includes anaesthetists, radiologists and pathologists. Not clever enough to remember the names of all those obscure diseases and which drugs won’t cure them, but far too cerebral to wield a scalpel or hammer, they spend their time helping the physicians and surgeons to look after their patients.

Physicians

Being so clever, physicians do a lot of thinking. Well, they have to do something when they’re at work. Physicians don’t operate. They don’t put people to sleep. They don’t report on X-rays and scans. There are lots of them in most hospitals, looking after patients with heart and breathing problems, diabetes, strokes, epilepsy, arthritis, over-active and under-active thyroids, and a whole host of other diseases and medical conditions that nobody but them has ever heard of – except for the poor sods who actually suffer with those diseases and medical conditions. Physicians come in more varieties than Heinz, so the following list is far from exhaustive.

General physicians.

These now rare beasts roamed the plains of the medical wards in massive herds when I was a medical student and house officer. However, they’ve since become almost extinct because they were unable to compete for hospital territory with newly evolved specialist physicians. It’s a shame, because general physicians were holistic doctors who treated the whole patient rather than just one disease or medical condition in isolation.

Cardiologists, aka heart doctors.

These are the ones to see if you’re having a heart attack or your blood pressure is through the roof. They are the experts at diagnosing heart murmurs through their stethoscopes that nobody else can even hear. That might sound impressive, but a scientific study years ago demonstrated that consultant cardiologists were no better than medical students at diagnosing valvular heart disease using only a stethoscope. Fearing for their professional reputations, cardiologists successfully reinvented themselves to become interventional cardiologists, who insert stents into the blocked coronary arteries of heart attack victims under X-ray control. Great news for patients, who avoid having to undergo major open heart surgery; less great news for cardiac surgeons.

Respiratory physicians, aka chest doctors.

They mainly look after patients with asthma and chronic obstructive airways disease. If your GP refers you to one for a flexible fibreoptic examination of your upper airways (bronchoscopy) because of a persistent cough, you might want to make sure all your affairs are in order.

Neurologists, aka nerve doctors.

You’ll find yourself under one of these if you’ve got epilepsy, Parkinson’s disease or any of a myriad number of weird and not so wonderful degenerative neurological conditions like motor neurone disease, muscular dystrophy and multiple sclerosis. Amongst the cleverest of the physicians, their talent is largely wasted because there isn’t an effective curative treatment for many of the conditions they manage. They end up spending a lot of their time reassuring battalions of worried-well patients complaining of recurrent headaches that their scans are normal and that there really is nothing wrong with them.

Endocrinologists, aka diabetologists.

They do treat other conditions apart from diabetes, but the vast majority of their patients do have a blood sugar concentration higher than a can of Coke.

Rheumatologists, aka arthritis doctors.

Every rheumatologist I ever encountered during the course of my career impressed me with their stellar intellect, encyclopaedic knowledge and quietly spoken manner. They look after people with rheumatoid arthritis and other chronic inflammatory systemic conditions. They’re the only group of doctors who routinely treat their patients with 24-carat gold. They send all their failures to the orthopaedic surgeons (see later).

Oncologists, aka cancer chemotherapy doctors.

Although definitely not the group of doctors you ever want to be professionally acquainted with, oncologists have transformed the prognosis of so many patients suffering from advanced leukaemia, lymphoma and many other cancers from being the virtual death sentence they were at the start of my training to being entirely curable in many instances.

Geriatricians, aka Department of Medicine for Older People (DMOP) doctors.

The terms geriatric patient and geriatrician are apparently no longer PC for reasons I don’t really understand, and have been replaced by ‘older patient’ and ‘physician for older people’. Given that a 30-year-old is older than an infant, does that make the 30-year-old geriatric? I digress. When I was at medical school, a professor of geriatrics (that was what he was, then) lectured us. We were amazed when he told us that, soon, a majority of hospital inpatients would be over the age of sixty-five, the threshold at the time for being labelled geriatric. It couldn’t be true, we thought. Hospitals, full to the rafters with old fogeys. He was just bigging his part, surely. But he was dead right. These unsung heroes do a fantastic job in difficult circumstances.

Paediatricians, aka kids’ doctors.

Working at the other end of the age spectrum, as a parent, you’d rather be seeing an oncologist about yourself than taking one of your children to see a paediatrician. A subset of paediatricians (neonatologists) think a 2-year-old is verging on the geriatric (apologies, I mean verging on being an older child), and limit themselves to looking after poorly newborns on the special care baby unit (SCBU).

Psychiatrists, aka mental health doctors.

As mad as the patients they treat, it’s impossible to tell the two groups apart. When I was a fourth-year medical student, I was asked by the registrar on my first day of psychiatry to assess one of the inpatients, a 52-year-old man called Colin, who had been sectioned under the Mental Health Act. I went to his room, only to find it empty. I looked in the day room, but he wasn’t there either. ‘He’s in the smoking room,’ piped up a dishevelled, ancient woman in desperate need of a shower, breaking off from watching the TV and pointing over to her left.

I wandered over in that direction and peered into the acrid cloud of smoke billowing from inside the doorway. I could vaguely make out two silhouettes sitting opposite each other, one male and the other female. ‘Could I speak to you?’ I asked the man. ‘Sure,’ he replied, stubbing out his cigarette. He followed me into the seminar room, and I got straight down to business. Half an hour later, I could well see why he had been sectioned. I had made a diagnosis of paranoid schizophrenia, complicated by manic-depression and sociopathic personality disorder. I finished my note-taking with a flourish of my pen and said, ‘Thank you very much for your time, Colin.’

‘Oh, I’m not Colin,’ he replied, ‘I’m Dr Derrington, one of the consultant psychiatrists.’

Community Medicine doctors and epidemiologists, aka your guess is as good as mine.

I’m not sure what this lot gets up to. Nobody does. Something to do with making national health policy. Their motto is: prevention is better than cure. With the UK’s spiralling prevalence of obesity, diabetes, hyperlipidaemia, hypertension, alcoholic liver disease, cancer and dementia, to name but a few conditions, there is clearly still work for them to do.

Emergency Medicine doctors, aka A&E doctors.

These doctors really are generalists extraordinaire. Working in what used to be known as Casualty, the Accident and Emergency Department, or simply A&E, but is now the Emergency Department (ED), they have to take all-comers from the victims of major trauma to timewasters with a sprained ankle; from patients with perforated appendixes and bowels to those with simple indigestion a couple of Rennies would settle; from patients who have collapsed after a brain haemorrhage to idiots complaining about the tension headache they’ve had for the past ten years and have only now decided to present to the ED with because there is nothing on the telly tonight.

You have to feel sorry for ED doctors. I know I do. They are tasked with managing an exponentially increasing number of patients while the primary healthcare and social care sectors collapse around them, often working in dilapidated buildings designed for a fraction of the number of patients flooding through the front door, with an even smaller fraction of the required number of trained staff to safely treat those patients in a timely fashion. I can see most ED doctors and nurses burning out or taking early retirement to avoid burnout, which will do nothing to help the staffing crisis.

Acute physicians, aka Medical Assessment Unit doctors.

The newest kids on the block, this specialty didn’t even exist when I started out. As long as your admission diagnosis is medical rather than surgical, acute physicians will look after you for the first 24-48 hours after you’ve finally made it through the back door of the ED into the one empty medical bed in the entire hospital (which will still be warm from the previous occupant and possibly a bit smelly if the nurses haven’t had time to change the sheets). The medical assessment ward is one level down from a High Dependency Unit, and you stay there while your acute medical condition is treated and stabilised before moving onto the cardiology ward, respiratory ward, diabetic ward, stroke unit, etc.

Intensivists, aka critical care doctors.

I’ve saved the best till last. I worked as an intensivist, spending roughly half my time caring for the sickest patients in the hospital, in the Intensive Care Unit (ICU) and the High Dependency Unit (HDU). The other half of my day job as a consultant anaesthetist was gassing patients in the operating theatre, of course. That critical care is an important part of many anaesthetists’ job descriptions is not well appreciated. A minority of the general population is aware that anaesthetists have any role in the running of ICUs, let alone that the majority of intensivists are anaesthetists.

From a patient’s perspective, needing to see me in my professional capacity as an intensivist is even worse than having to see an oncologist. Although the chances are you won’t be conscious when you meet me because you’ll be at death’s door in a medically-induced coma on full life support. It will be down to your nearest and dearest to have a few cosy chats in the Relatives’ Room with me about your chances of survival. Intensivists are right up there with the ED doctors in terms of their risk of burnout from decades of working long hours without a break, cumulative sleep deprivation and the constant stress of having to make life-or-death decisions.

Any junior doctor who decides to become an intensivist is making a really bad choice. They are always being called back into the hospital out of hours and have a curriculum of required knowledge that encompasses everything all the other medical and surgical specialities need to know plus their own Intensive Care stuff. Loads of their patient die despite their best efforts. A word of advice - become a dermatologist or an ophthalmic surgeon. Virtually no out-of-hours work and tons of private practice. Marvellous.

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Coming soon...

Dr Tony McCluskey — Wed, 1 Apr 2026 00:00:00 +0000

I will be posting a series of articles in this blog about hospital life soon. Entitled Who’s Who and What’s What: Inside NHS Hospitals, it's an insider's guide to how hospitals really work. The series will attempt to inform, explain and demystify what it is that doctors, nurses and all the other clinical specialists get up to behind your back if you're unlucky enough to be admitted to hospital.

Here are some of the topics I'll be covering...

Making sense of all the different medical and surgical specialties.

Medical terminology and acronyms explained.

The difference between a heart attack and a cardiac arrest.

How cardiac arrests are managed in hospital.

What you can do to manage a cardiac arrest until the emergency services arrive.

What's brainstem death? Surely you're either properly dead or still alive.

Organ donation.

What is general anaesthesia?

What happens on the Intensive Care Unit?

Why are some hospital doctors referred to as Mister and other as Doctor?

What's the difference between a radiologist and radiographer?

Why are there so many junior doctor grades? And why are juniors sometimes called trainees although now resident doctors is the preferred term?

Hospital managers - who are they and what do they do?

What does a coroner a do?

What goes on in the doctors' mess?

How do the different areas of a hospital work?

Why does parking your car at your local hospital cost so much and why can you never find a place to park anyway?

What is being on call like and how does it relate to stress, mental and physical health problems, and burnout?

How do I see the future of the NHS?

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Why I wrote my story

Dr Tony McCluskey — Wed, 1 Apr 2026 00:00:00 +0000

On 4 June 2020, the GMC (General Medical Council) wrote to inform me that it had erased my name from the UK register of medical practitioners and revoked my licence to practise. In other words, I had been struck off. I hadn’t done anything wrong. I had taken early retirement to escape the relentless pressure and stress of life on the NHS frontline as a consultant in anaesthesia and critical care medicine. After forty years, I was burnt out. The letter from the GMC marked the formal conclusion of my medical career. I was no longer entitled to call myself a doctor. If I did try to pass myself off as one now, I would be breaking the law.

I had a vocation to become a doctor and to minister to the ill, diseased, injured and dying from as far back as I can remember. At least, that’s what I think you expect me to say. In truth, however, I never really had that vocation thing. I hadn’t the foggiest idea what I wanted to do with the rest of my life while I was at school. Lawyer? Teacher? Particle physicist? Airline pilot? Doctor? Who knew? I certainly didn’t. I had to choose something to study at university, though, so I plumped for medicine. My decision pleased Dad, and my best friend had applied to go to medical school. Plus, doctoring was a steady job with kudos and paid well.

I was an anaesthetist for nearly all my career. Most people have only the vaguest notion of what an anaesthetist does, their knowledge acquired from watching medical dramas on TV. An intravenous injection of a sedative draught or a whiff of gas sends the patient off to sleep. At the end of surgery, an antidote is administered, or the gas is simply turned off, and the patient wakes up. In between times, there’s nothing much to do except complete The Daily Telegraph cryptic crossword. Simples. Surveys show that half of the general population does not know that anaesthetists are medically qualified doctors. A patient once asked me what it was like to be an anaesthetist. I was delighted that she was so interested, and I enthusiastically gave her chapter and verse about what a fascinating and professionally challenging job it was. My bubble burst when she remarked, ‘I think my son would like that. He didn’t get high enough grades to get into university. Being an anaesthetist would suit him down to the ground. Can you study it at night school?’

The main reason people take that view of anaesthetists stems from their ignorance of what general anaesthesia entails. As anaesthetists, we don’t help the cause by casually referring to the induction of general anaesthesia as “going to sleep”. Such language only serves to reinforce the picture of a patient dropping off into a deep, contented, peaceful snooze, little different and no more risky than taking an afternoon nap on the sofa after a huge Sunday roast. In reality, general anaesthesia has almost nothing in common with regular sleep. It is a state of deep, unresponsive coma. An anaesthetised person is as close to death as it is possible to get without actually being dead. A deeply anaesthetised subject undergoing brainstem function testing would be diagnosed as brainstem dead.

A consultant anaesthetist studies to become a doctor at medical school for five or six years and then trains in hospitals as a junior doctor for another ten years or so. I would argue that this length of time is hardly necessary to learn how to induce this state of deep, unresponsive coma, which any Tom, Dick or Harriet could do with minimal training. But it is essential to ensure you safely wake up again from your deep, unresponsive coma, and without your brain having been scrambled or you suffering any other serious adverse sequelae.

Giving anaesthetics in the operating theatre was only half of my job as a consultant. The other half was spent caring for critically ill patients in the ICU (Intensive Care Unit). Critical care is another part of an anaesthetist’s job description that is not well appreciated. Most people are unaware that anaesthetists have any role in the running of ICUs, let alone that most intensivists are anaesthetists. Anaesthetists also work on the labour ward, inserting epidurals, and in chronic pain clinics. They lead cardiac arrest teams and teach other doctors, nurses and paramedics the principles of resuscitation. In fact, there is almost nowhere in the hospital where you won’t find an anaesthetist, and 70% of all hospital inpatients encounter an anaesthetist at some point during their admission.

I thoroughly enjoyed the challenges, the job satisfaction and the privilege of being a doctor, but the positives came at a price. My wife will tell you I often wasn’t there for her or our two daughters. When my girls were growing up, I missed out on meal times, bath times and bedtime stories; playing in the park, birthday parties and days out; school concerts, parents’ evenings and sports days. My work-life balance was often unbalanced, and the years of toil took their toll. When I reached my early fifties, I realised I was suffering from burnout. Something had to change, and I made plans to take early retirement.

The last patient I anaesthetised woke up on Tuesday, 31 March 2020, at 12:45 pm. My logbook records his details: 61-year-old male; ASA III; elective ureteroscopy and laser to stone; surgeon Miss Greene; general anaesthesia; tracheal intubation; uneventful.

After his operation, I handed over his care to the recovery nurse, went to the changing room to get dressed and walked out of the hospital for the final time as a doctor. There was no fanfare, impromptu party, handshaking, retirement present or speeches. I left unnoticed as if it were any other day. But these were extraordinary times. The COVID-19 pandemic was gearing up. An awful sense of impending doom pervaded the hospital, and normal service was suspended.

Even though I was retiring, I expected to return to work after a fortnight’s break. With the anticipated tsunami of critically ill coronavirus victims rapidly approaching, my medical director had asked me if I might ‘possibly come back to help out for a bit,’ and I’d agreed. As it turned out, my further services were not required.

When I reflect on my adventures at medical school, on the wards, in the operating theatre and in the intensive care unit, and recall the patients I have been privileged to meet and care for, I can scarcely believe it all happened. There were times of great joy and times of even greater sadness. I achieved much that I am proud of. However, there were many occasions when I experienced intense frustration. Triumphs were counterbalanced by tragedies; hilarity by horror; mundanity by absurdity. Mentally replaying all these events is like watching the scenes of a movie. Those scenes are the chapters in these three books.

To answer the question posed at the beginning of this post, I decided to write my story, first and foremost, to prove to myself it really did happen. In the process of transferring my memories into my memoirs, I relived so many experiences and remembered so much I thought I had forgotten. Reading my books has helped me appreciate how lucky I was to enjoy a long and successful career as a doctor. If you read them too, I hope you'll be moved. At times, they will make you laugh, at others they will make you cry. You won't believe some of what goes on, but trust me it does! Reading my life story won't only be an entertainment, it will be an education.

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