My date with Sister Scope

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Stats nerds and propellor-heads aside, humans are crap at probability. ¹ It’s not that we can’t do sums. Weaving the lanes of a crowded M1 at 70mph, cutting a zig-zag across a busy junction on foot or leaping for a cricket ball, we effortlessly make complex appraisals of speed, vector and angle. And we do so intuitively, seldom erring.

That’s likely because we’ve been making those calculations for 100,000 years or so, hurling flint spears at woolly mammoths and legging it from sabre toothed tigers. With all that evolutionary wind in our sails, we’re pretty good at this kind of thing.

But only in recent decades have we been called upon to make assessments of probability which draw on large and by that fact abstract data sets. Our ineptitude here is telling. As is the flaky reasoning we come out with if we aren’t expensively educated; else push down to netherworlds of the brain stem if we are.

Everybody knows a bloke down the pub who knows a bloke down some other pub whose Uncle Sid smoked eighty a day and died aged ninety-eight while shagging Auntie Ethel, or whose fifth cousin thrice removed’s hairdresser was the sole survivor of a motorway collision – not despite but because  she hadn’t  been wearing a seat belt.

I’d hate to be unduly reductive. When these and other such tales are being traded and trumped, there’s usually more than one engine doing the pushing and pulling:

• we’re gonna smoke anyway, or make that two minute drive to the offie without the faff of fastening in, but feel obliged to put up a show of intellectual justification;
• we love counterintuitives; a gleeful fuck you  to the tyranny of accepted wisdom;
• AND we’re crap at probability.

Park that thought. I’ll be back, though I may be a while.

*

I don’t say the nurse in green – all rubber gloves, cap and gown – is smirking. How would I know? She’s masked up for covid. But to my wary eye she’s a far cry from not  smirking. That glinting of the eye, as she points to the couch, telegraphs gallows humour long before her words are out:

“Go on. You know you want to!”

I’ve been in the cystoscopy room fifteen minutes without so much as loosening my belt, far less unsnapping my 501s. Meeting her gaze, I respond in kind.

“No thanks. You’re all going to pounce on me and stick things up my willy.”

All? A cystoscopy requires three hands on dick deck: one to secure the object at the epicentre of things – limp, forlorn and shrinking in vain to absent itself – as two others thread a narrow tube (how narrow?) along nerve-rich pipework whose owner’s sole protection from pain (though not indignity) is a numbing gel, syringed like cake icing into the orifice of inordinate sensitivity.

In, in and thrice in!

In further!! 

In all the way, passing the prostate (worst part, I’ve gathered, in the face of strong competition from other anatomical hot spots) till the miniature spy-cam at the business end has defeated gravity, decorum and other spheres of resistance too hair-raising to dwell upon, and snaked its insanely invasive way into the bladder to snap away like David Bailey.

Nobody has three hands. Even without the high likelihood of a fourth being needed to soothe or slap the patient into line, it takes three people – two cystoscopers and one cystoscopee – to do this particular tango.

So why do I – no maths wizard but in the top half of the class on mental arithmetic – count four of us in the room?

*

Seventeen days earlier. A Saturday morning in late November sees me in a line stretching out of my GP’s surgery and curving around the staff car park. We’re waiting for our third covid jab and, in my case, the standard flu shot I should have arranged months ago. The procedure honed with military precision, I’m through the surgery door within five minutes and baring each arm in turn within ten.

I’m told to stay a further ten in the waiting room before buggering off, in case I have an adverse reaction. I give it five. For the next few hours I feel like somebody punched me in each bicep but am otherwise fine. Then I start peeing blood.

To be clear: I don’t say either of the jabs, and what clinicians call gross haematuria, are causally linked. But I’d have to be one of them there coincidence theorists  to rule it out, wouldn’t I? ²

On Sunday the flow is dark crimson but now I see – and feel – flocculent clots passing through, like fine tufts of cotton wool. That’s a tad scary. Ten years ago I spent four catheterised days on a hospital ward, an experience I’ll be returning to before I’m done, because they weren’t going to send me home until my pee ran pale golden clear, with no danger of post biopsy blood clots blocking the urethra.

Scary or no, on Monday morning I drive up to Sheffield for a date with an electrician. But as it turns out, destiny has other ideas. After coffee in Sainsbury’s just after nine, I heed the call to point percy at the porcelaine. Only to find I can’t emit a drop.

Things just took an alarming turn for the worse.

I’ll pass over much of the day’s horror. I get myself to a nearby walk-in. (It’s crowded of course, and grossly understaffed so we’ll welcome with open arms the shining knight of privatisation.) My experience of NHS walk-in clinics is that when you finally do see a medic, you usually get good care from someone who may be visibly exhausted but is not too far gone to hear you out.

Boy, do you have to wait though!

By the time I see a nurse it’s four pm. I haven’t peed since getting into my car at seven-thirty for the drive up the M1 – though I’ve sat on a succession of pub loos, for upwards of half an hour at a time, my reward a few bloody droplets. Ordinarily the very idea of the catheter inspires shock and awe, fear and loathing. ³

Now I’d kill for it.

She can’t oblige – ‘we don’t have the kit here’ – but is kindly and decisive. As I pace her domain, slowly leaking into my jeans – beyond embarrassment but gaining scant relief from the single drop seepage, every other minute, through blood clots I assume to be impeding the flow – she calls Urology at the Royal Hallamshire to secure, with no small firmness on her part, a promise that I’ll be seen on arrival. Leading me back to reception she has the lady call a taxi. Have I the money for the fare? Provided they’ll take plastic, I tell her.

She turns again to phone lady. ‘Put it on my account.’

*

It’s rush hour. The taxi is late. Nor am I seen right away, though Nurse Walk-in got ten out of ten for effort and persuasive skills. As I pace the waiting area like a defective robot, I hear a bellow from an adjoining room. Startled out of my own vanishingly small perspective, I read it as work-place joshing of the kind familiar to me from salad days on shop floor and building site. Then I hear it again. Hypothesis refuted. There’s no-one larking around here. Depend on it: yon side of that door some CIA goon, muttering darkly, is subjecting a man to enhanced interrogation.

Or to the dreaded catheter. Yes, that’ll be it. Hence that third voice, soothingly female.

I bet the ladies slide it in with greater care. But does the recipient ever get a hard-on? 

Highly unlikely, I decide. All things considered.

The cries continue for a minute or so, then I hear a very different but equally involuntary sound; barely distinguishable from that moan of beatific surrender in the aftermath of an exceptionally powerful orgasm. It’s followed by the voice, now recognisable to me, of the male nurse who’d greeted my arrival:

There you go. Wasn’t that worth all we’ve had to put you through?

Soon be my turn, I tell myself. And you know what? For all I’m a total jelly-baby when it comes to pain, right now I can’t wait. Bring it on!

*

Half an hour later, I’m still pacing. The nurse of rough but kindly manner appears. He opens an examination room door, addresses me by name and bids me enter.

In you go, Philip

At last! But no, he leaves me alone in that room. I’m there the best part of an hour, sitting on its couch, jeans at thigh level not because I’ve been so instructed but to lessen, if only by seconds, whatever further delays I must endure.

My boxers stay for now in situ; sodden, but I have a card up my sleeve. Anticipating this sorry state of affairs while walkin’ to the walk-in, I’d nipped into Primark for boxers and cheap jeans. Nestled in a paper carrier bag at my feet, they too await their moment.

It occurs to me that my man had clocked the way I’d paced that waiting area, legs knotted as I stared balefully down at my crotch. Even at thirty drips to the hour, I’d hit the limits of denim’s capacity to absorb body or any other kind of fluid. In other circs I’d have been watching the lino at my feet for the first pooling signs of final humiliation. Now such trivialities count for nothing.

They can catheter me starkers on a floodlit stage. Just let it be now!

All the same, I reckon I’ve been put here not because anyone remotely competent is remotely ready to see me, but to spare my dented dignity. Or others’ sensitivities. Or the waiting room floor. Or all three.

At long last my man returns to hear my story. I’m not too far gone to register his swift dismissal, in our polarised times, of any link between current plight and those Saturday morning jabs. But I don’t press the point. I crave deliverance, not debate.

He rules out the catheter. The clots, it seems, place that on the wrong side of iffy. The risk is of compacting rather than piercing the blockage. I’m close to tears. So what now?

I’ll see what the doctor says, but what we really need from you is a urine sample. ⁴

Jeez – if I could give you that I wouldn’t be here, would I?  But I keep such unhelpful commentary to myself. Call it Stockholm Syndrome but I’ve warmed to this guy. And my instincts tell me, as they had with Nurse Walk-In – she of the taxi budget – I’m in good hands.

*

Fifteen minutes after Nurse No Catheter’s exit for doctor’s orders, the miracle happens. Without warning I sense the dam breaking and leap to my feet. The loo is out of the question but in one corner, a single step from the couch, is a washbasin. I’m there in a nanosecond, front of boxers shoved down in readiness.

I’ll use the washbasin if I have to but, mindful of what nurse said, I eyeball the room. Zilch. But what’s this? On a window ledge above the basin, within arm’s reach, sits a single instantiation of those grey cardboard containers designed for this very purpose. It’s chocka with clinical bric-a-brac but a flick of the wrist upturns it. Even as its erstwhile occupants – sealed syringes I think – are spinning across the sill and onto the floor, I’m holding it above the washbasin with my left hand while my right aims a dark red torrent to fill it to the brim. I can’t be sure I wasn’t actually weeping with joy: tears of gratitude to who knows what?

Sweet goddess of bounteous urination, hallowed be thy name!

The bliss of bladder release, I discover, can sweep aside modesty and decorum as effectively as the agonies and apprehensions of blockage. With container and contents nestling in the wash-basin, I pull up boxers and jeans, fling open the door and go dancing out.

I must cut a wretched figure. Damp denim bunched in fist to forestall downward slide, I scan the waiting area. A few blokes escorted by a wife or two barely register. Through an open doorway at twenty paces I spy my man shooting the breeze with colleagues.

Hey! I got you a sample!

Pause.

And it’s got blood clots in it!

Too much information for so public a space? Am I bovvered? The nurse, to his undying credit, comes running. Back in the room of relative privacy he draws a syringeful, then turns to me.

You’ll be thrilled to know this is old blood. Look at it! It’s more rust coloured than red. The source of all this, wherever it is, has stopped bleeding.

Sod’s law, innit? Now that I can wait in serenity – wet denim, where is thy sting? – I don’t have to. As Nurse No Catheter leaves with sample, a young woman enters. Peering over her covid mask she introduces herself as a student nurse and asks if I mind answering a few questions.

*

I take her through the chain of events set out above, adding that ten years ago I had a prostate scare. Reporting to my GP, back in 2011, that I needed to pee more often and the flow was not what it had been, I’d been referred to this very hospital. This very department in fact.

Over several visits I’d lost count of the times I’d had a DRE – not the rapper – and on three of them had biopsical darts fired up my bum to snatch samples of prostate tissue.

(I never saw the gun. They didn’t offer, I didn’t ask, and my eyes weren’t the part of me turned towards it. But in my mind’s eye I saw it as one of those kids’ toys that fire corks with strings attached for ease of retrieval.)

The gun wielding consultant I remember well. I’d been advised to leave socks on, the hospital floor being chilly. Ever noticed how you feel twice as naked when socks are all you have on?

I lie. On each occasion I’d have changed into a cotton gown. But the nurse sitting in without my say so (to forestall, I now realise, accusations of sexual assault) had bid me raise it north of the waist, so the more-is-less rule still applied. The socks and nothing but the socks only serves to heighten, the exception proving the rule, that sense of being naked and eyeballed by a bunch of strangers who aren’t.

And no, I never did get the logic of that oft-parrotted, ‘”they’ve seen it all before”.  Yes. And? It isn’t their sensitivities I’m bothered about.

The consultant, of the hail-fellow-well-met school, had a high opinion of his God-given ability to put the patient at ease. Did he think his line of patter an ice-breaker, a sure-fire normaliser of the humiliatingly abnormal? Was he road testing what he’d taken away from that mandatory half-day course on interpersonal skills last summer?

Whatever. The first time he came at my bared and puckered he’d seen fit to precede the dart play with an assessment of my hosiery: black, with mauve heels and toes.

Hmm. Love the socks. Marks & Spencers unless I’m much mistaken.

I’d faked an appreciative tee-hee. Given our respective roles in this comedy of arrows, it seemed the smart thing to do. And FWIW, he wasn’t wrong. The socks were indeed M & S.

Be that as it may – and I’ve had clinicians behave far worse, ⁵ while the tissue grabs were more disconcerting than painful – it came to pass that, after three such ordeals at twelve firings per session, I found myself once more in that same room. Fully dressed for once, and smiling at the nurse – middle aged and plump, Afro-Caribbean and totally fanciable – I heard him deliver the lab verdict on thirty-six darts up the derriere.

Looking good. But there’s one part of your prostate we can’t get at this way. To be on the safe side we need to fire a few up your john thomas …

Who the fuck in this day and age speaks of a ‘john thomas’?

Not that this was uppermost in my mind. Either because he registered my horror, or because he’d anticipated and savoured it for a few seconds before putting me at ease, he went on to assure me I’d be asleep.

On that basis I signed up for a fourth and frontal biopsy. I didn’t then know about the liberties consultants and their students frequently take – in a teaching hospital – with the anaesthetised patient. To this day the ethics are grey, and notions of what does and what does not constitute informed consent a matter of muted debate. Consider this old hand, urging medical students san frontieres  to set their misbegotten scruples firmly to one side:

1. I once foxed a colleague with this teaser: ‘Assuming unloaded dice, which number are you most likely to throw in a Monopoly game?’  His reply was delivered in the sniffy tone of one with a maths Ph.D (why else would I have picked on him?) at so insulting a test. ‘If the dice aren’t loaded, all six sides have equal likelihood of landing face up.’  Ha! What he’d overlooked is that two dice, not one, are rolled in Monopoly. The right answer is seven. Double ha! With brass knobs on.
2. You could say the way to falsify a putative link between jabs and haematuria would be to ask whether anyone else, with particular emphasis on those having third covid and flu shots, has reported such a reaction. But a mix of litigatory fear and a super-charged covid debate leaves me doubting I’d get a reliable answer.
3. Actually there’s a subgenre of kinky that gets off on catheter play. Nowt so queer as folk, eh?
4. Now I can reflect on Black Monday, it dawns on me that what bothered the urology crew at Royal Hallamshire, and what bothered me, were not at all the same. I think they, in their greater wisdom and experience, knew I’d be peeing sooner or later, and were looking further ahead at what unholy conditions the blood might be indicating. By contrast, such abstractions lay beyond my sharply reduced attention span.
5. Credit where it’s due. Though I never did warm to his gung-ho style, and won’t easily forgive his trespasses via that first year student, I not only sensed that Dr Sock knew his game. He was also capable, once he dropped the irksome manner, of engaging me in non patronising discussion of what the lab reports might mean. (Biopsies are akin to opinion polls: samples, with all the caveats to generalisation that implies.)
6. Actually, it’s worse for Brits. Some US states have in recent years passed laws banning unconsented intimate examinations of no direct benefit to the patient. Britain has not, though some health authorities have had their HR, PR and legal people firm up their policy statements.
7. My trawl of sites on the ethics of intimate examinations of sleeping patients returned student reluctance as a major recurring theme, but rarely if ever does demurral lead to defiance. For light on this, see the work of Milgram and Janis – and the many cases in the history books of conscience playing second fiddle to conformity.
8. Take my own ‘front-port’ prostate biopsy. Dr Sock had spoken of a simple op, with me going home that night. But at 07:00 on the day, another consultant told me I’d be in for half a week or more. He then reeled off at horse race commentary speed a list of side effects – ‘unlikely but possible’ –  taking in such joys as impotence and lifelong incontinence. At that time, sneaky training routines as clinically tangential as they were intimate hadn’t been on my radar. And if they had been?  They’d have barely registered, given the competing calls on my capacity for anxiety. In a daze, coffee having been forbidden, I signed on the dotted line. Informed consent? I think not – and of course, I don’t know and never will what took place that day. I know only that three smiling ladies in green counted me down to oblivion, and that when I awoke, with no sense of the passage of time, I was on a ward with catheter running from bladder, by way of John Thomas, to a transparent bag hung from portable gallows for the world – visiting families for instance – to see. Whatever happened between-times is anyone’s guess but I will say this. In 2011 nurses were getting a stack of bad press, led by tabloid tales of poor hygiene and worse manners. For the four days and nights I lay as described, at the mercy of their hands-on intimacies, I was blown away by the professionalism – the real kind, not the inane vacuities of HR-speak – they not once failed to show. One day I’ll post on this. Any professionalism worthy of the name, in the medical or my own teaching context, is about wanting to do the right thing; not fear of being caught doing the wrong thing.
9. Yet another option, practised in parts of the USA, is to employ surrogates to let their bodies be used for training purposes. Yes, the objection will be that a cash-starved NHS can barely pay its drugs bills. To which my reply – implicit in the contents of this entire site – need not be spelt out here.
10. After each rectal biopsy at Sheffield’s Royal Hallamshire I was asked before leaving to give a urine sample, and sit with it in a crowded waiting room till a nurse eyed it up for blood before letting me go. Sound practice, as I would appreciate ten years later on Black Monday. Less sound was the huge transparent beaker supplied. (The small vial given on my Nottingham visits this year could – once sealed, washed and dried with a paper towel in the loo – be slid into a pocket.) Such indignity was compounded by a waiting area wherein men clutching beakers of wee shared space with accompanying women and kids. When we – and everyone else – heard our name called we were to trot meekly to the nurse’s station with our samples for inspection. Crass, and here too the contrast with Nottingham is unflattering to Sheffield. Urology outpatients at the former have a private waiting area: no friend or relative admitted without good cause. (The elderly man awaiting cystoscopy on December 8 was in a wheelchair, hence the wife’s presence.) After my first biopsy I did as I was told. After the second and third I judged myself capable of spotting blood without a second opinion, and voted with my feet. (I do allow, however, that what is really being compared here may not be Sheffield’s Royal Hallamshire and Nottingham City Hospital, but 2011 and a more enlightened 2021. If anyone has up to date information on this do let me know.)
11. In the USA it’s common, I’ve learned, for a doc about to do a DRE or pelvic to call the front desk and summon a receptionist to stand in as ‘chaperone’. What we lay folk need to wise up to is that our awe of a medical priesthood is being hugely leveraged by the arrogance of many – I don’t say all – whose intentions may well be benign, but whose complacency stinks.
12. Not her fault at all. Being eighteen is no crime, and ten years on she may now be a glowing credit to her chosen profession. What’s more, her presence that day helped clarify my thinking. You could say I owe her.
13. I know two men a few years my senior who, aware they have prostate cancer, have no intention of doing anything about it since, unless it becomes aggressive – quite rare – they’ll die of something else. Thermonuclear war for instance.
14. I use the female pronoun because the one person who made no contribution to the cystoscopy room dynamics was a woman in the far corner behind a desk. But with Nurse GownGlove and me the only parties I could identify as indispensable, I can’t rule out the passenger – once the time for words had passed – being Nurse Andy.
15. Hours after uploading this post my copy of a letter from Nurse Andy to my GP arrived. It housed this sentence: ‘I discussed … with Mr Roddis and on careful consideration he was not wanting to go ahead with a flexible cystoscopy despite the risk of missing underlying bladder cancer’. As a matter of fact, as agreed with Nurse Andy on the day, I had an ultra-sound bladder scan a few days later. Subject to the lower diagnostic power of this procedure, it gave me the all clear.