The Patient (16 page)

The other officer knocked on the door to the Quiet Room. ‘Mr Sawyer?' he asked, with what sounded to Jonathan like feigned concern.

‘Yeah. Dad, the cops are here to speak with ya!' a tall man with the most tattoos yelled over his shoulder. Then he turned back to the policemen and said in a quieter voice, ‘He's very upset. Do you think you could keep it short, mate?' Jonathan guessed they were the family of the man in the resuscitation bay. The dead man.

Jonathan found the toilet and pushed on the door, but it was locked. He stood for a minute deciding whether to go into the handicapped toilet. Just then, the door swung open.

An Asian man wearing the saffron-coloured robes of a Buddhist monk stepped out and, smiling, held the door open for Jonathan.

‘Oh. Thank you.' Jonathan just stood there keeping the door open, watching the man walk down the corridor. He was an old man and yet had the spritely step of a 12-year-old. Though Jonathan had only looked into his face for a few seconds, he was tremendously struck by the man's radiant smile. It was not a forced smile; it was a smile from within, a smile that was unintentional, unavoidable, a smile that Jonathan imagined said, ‘I know what there is after all of this, and it is fine.'

Jonathan went into the toilet, and as he urinated he looked at his face in the mirror to the side. He hadn't shaved for several days. He looked like some haggard criminal.
Dark rings surrounded his eyes. Deep wrinkles scored his face. Counting back, he realised he hadn't showered in three days. He smelt his armpits. They were almost fishy, putrid.

He washed his hands and went back to his cubicle.

In a cubicle on the opposite side of the room, the Buddhist monk was attending a very old man in bed. The priest placed his hands together in a prayer position and raised them to his forehead before entering the room. Jonathan had seen this action in India, where Tracy and he had gone before they got married, in the days before children, loans, mortgages and responsibilities. The beggars on the streets and the porters at hotels would raise their hands in that prayerful position towards him and Tracy. He never felt deserving and would reward them with large tips.

The monk, as if sensing Jonathan's gaze, suddenly turned around. He faced Jonathan and raised his praying hands again and bowed. That radiant smile was so overwhelmingly disarming. Automatically, without any thought, Jonathan placed his hands together and bowed towards the old monk. They shared a moment of peace and compassion while the patients around them went about the business of suffering and the doctors and nurses went about the business of tending to their suffering.

Sometime later, as Jonathan was floating between sleep and wakefulness, he looked up to see the monk at his bedside.

‘Do you mind if I sit?' asked the monk.

‘No, please do. I could use the company,' answered Jonathan. ‘You're a Buddhist, right?'

The man nodded and smiled that smile again.

‘So, what do you make of all this, then?' asked Jonathan, with a sweep of his arm to indicate the Emergency department.

The monk turned and surveyed the room, then turned back to Jonathan and answered, ‘Doctors rush here and there to fix up the bodies of these people. Nurses run to help ease their pain. Meanwhile, above it all, beneath it all, there is a truth from which none of these people can escape: suffering is part of life. Life
is
suffering.'

It was just like the woman had said at the restaurant with the lotus flower – only somehow this time Jonathan realised he needed to listen with the utmost attention. Here, beneath the fluoro lights of the Emergency department, these two men had silently forged a bond. Jonathan imagined they were travellers on a long trek, meeting in a teahouse along the way, swapping tales.

‘This world – and this body – is only a part of the journey. It's not a beginning or a destination. Everything changes, including your body. Everything is transient. In meditation, we try to learn to see all of this with calmness, contentment, with clarity.'

It was as if the joy in the monk's heart was contagious. A peaceful feeling the likes of which he had never experienced infused Jonathan. He, too, felt joy in his heart.

Noticing the calm expression on Jonathan's face, the old man said, ‘There is an inner ocean of calm that is not beyond you. It is
in
you, a space you can visit whenever you need to. It is like a room where all is quiet and clear, whose door is open to you whenever the spirit needs to heal.'

The registrar appeared at Jonathan's bedside again,
pausing to look quizzically at the monk. The old man stood, bowed, and with that was gone.

‘Mr Brewster?'

‘Yes. Oh, sorry. Yes, doctor?'

‘I have spoken with your doctor, and he feels we need to get you to the operating theatre today and examine your bladder again. It's obviously a worry that you're bleeding again.' The registrar's tone was blunt.

‘I'm due for another BCG today. Do I need to have that?' Jonathan was confused. How could he be operated on and have his BCG in the same day?

‘No. I'll ring them after nine and cancel it. If the doctor thinks you need to continue on that treatment, then he will arrange it again next week. Any questions?' The registrar was already walking away as he spoke.

Washington DC is a fabulous city. I had just been there for a week at a conference and visited all the sites, in between attending some of the conference sessions. It was a city of memorials: I had enjoyed reading the inscriptions on the Jefferson and Lincoln memorials in particular. Washington is also a city of contrasts. Georgetown University, in the area known as Northwest, is surrounded by some of the most affluent suburbs in the US. The diagonally opposite part of the town, the Southeast district, is among the most dangerous and poverty-stricken areas of the US. The shadow of the Capitol Building, an imposing visual feast of a structure, casts its cloak as the day progresses over the bitter poverty of the Southeast and the breathtaking affluence of the Northwest.

The hospitals of the Southeast offer care that makes some of the hospitals I have visited in developing parts of Africa look modern and cutting edge. By contrast, the hospitals of the Northwest are among the finest in the world. It all comes down to whether you can afford to pay for health care or not.

My plane home landed at 6 am, and I went straight to work at the Victoria Hospital. I hadn't slept on the plane. Economy class,
the smallest space that a person can physically fit into, is designed to ensure that sleep is not on the menu.

Damian handed over to me the various disasters that lay waiting. I was in my final weeks as a registrar, but he had been acting registrar throughout the week that I had been away; now, he handed the burden back to me with glee.

‘Oh, and finally, that young bladder-cancer patient came in overnight with bleeding. He's still in Emergency. Derek wants to cystoscope him. I don't think we're going to get to do it until late today. We have a lot of cases waiting.'

Securing time in operating theatres was a battle fought day and night by surgical registrars in all of the public hospitals in the country. The high emergency case-load was no surprise. Over the years, statisticians and health economists had plotted, with uncanny accuracy, the expected case-load of emergencies on any day of the week. The hospital bureaucracy knew that on a given day there would be x number of cases. And yet, being allocated times to operate on the multitude of patients that I and every registrar saw in Emergency each day seemed as difficult a task as finding a hidden treasure in the Andes. First, one booked the case on the emergency list. Then one waited while the super vising nurses or anaesthetists prioritised the cases and then slowly worked through them in order. Hence, if a patient presented to hospital with a knife in the heart, his or her operation would be done almost immediately. Top priority. However, if a patient came in with a broken arm, a stone blocking the kidney or bleeding from the bladder, the wait for surgery could stretch to several days. All the while, new cases were being seen and added to the list. Add elective surgeries such as hip replacements, prostate operations, hernia repairs and other cases of similar importance and the waiting list got even longer.

Much of a surgical registrar's time was spent battling for theatre slots. ‘I really think my case is more urgent!' the registrar would say.

‘Well, if you think so then you will need to speak to the other 16 surgeons who are desperate to do their cases also,' the anaesthetist or nurse would answer.

Long waiting lists are a major concern for a health minister because the longer patients wait for surgery, the more they complain. The list at the Victoria Hospital was huge. When I booked a patient in the Urology Clinic for their prostate to be operated on, they could wait up to 18 months.

The previous year, the health minister had been pleased to tell the public that the waiting list for elective surgery had been cut to zero. The media rejoiced. The reality was that the definition had been changed. Formerly, once a surgeon had decided a patient needed an operation, he or she put the patient's name on the waiting list. Now, they were to put the patient's name on the list only when the hospital had allocated the patient a time to have his or her surgery. By a stroke of the pen rather than a slice of the scalpel, the waiting list had been cut almost out of existence. The alternative, of course, was for the government to acknowledge that health resources were not adequately distributed. The operating theatres were one place that obviously needed more money, better organisation or greater efficiency.

Meanwhile, Jonathan sat in Emergency waiting for his operation for the rest of the day. It was almost seven in the evening when he was finally taken upstairs. I was standing at the doors that led to the theatre complex.

‘Hello there. You've been having some bleeding, Damian tells me. We will soon get to the bottom of it. How have you been?' I asked.

‘Not well, doctor. I've had enough of this business. Do you think it can be fixed today?'

‘All we'll be doing today is trying to ascertain where the bleeding is coming from. If the cancer has grown despite treatment, then we need to know about that. Your doctor is in just finishing a case. I'm sure he will come and discuss it with you further.' I placed my hand gently on the back of his, for reassurance. I did this instinctively. Years later, when I was to go through my own cancer ordeal, I realised how important human touch is. Through a simple reassuring touch, so much care, compassion and empathy can be transmitted. It is so much more powerful than words.

An orderly came to take Jonathan into theatres. He was working on his own, so I thought I would give him a hand. We brought Jonathan's bed into the anteroom adjoining the theatre where he was going to be operated on. The orderly placed the notes on the side of the bed.

‘We will be with you shortly,' I assured Jonathan. He just lay there looking so vulnerable. I felt sorry for the man.

I went into the theatre and told Vincent, the anaesthetist, that Jonathan Brewster was in the anteroom.

‘Is that the bladder cancer?' Derek asked.

‘Yeah, the one that's had the BCG and is now bleeding,' I answered.

I had interrupted an intense conversation the two men were having about the hospital review while Derek operated on a private stone case. Every now and then, there was a private patient on the list in the public hospital. Such a patient was generally referred to by medical staff as ‘MBF positive'. MBF was a large provider of health-care insurance.

I sat in the corner listening to their discussion and finished
the cup of coffee I had obtained several hours ago. It was almost iced coffee.

‘Anyway, they sent round a memo from administration. It was just crazy. It said something like the management is aware that there is low morale in the hospital, and so they are going to spend extra to have the clinical areas of the hospital cleaned. Can you believe that? Someone remind me: isn't a hospital supposed to be clean anyway? They were the ones who outsourced the cleaning in the first place, so it now costs more than it did before, yet the hospital is so dirty that our
morale
is affected. They just defy any form of logic known to man or beast.' It was Derek, shouting at the top of his voice.

‘Someone should show the memo to the people conducting that review the minister established. Have they asked for your views?' said Vincent.

‘Don't be stupid. The only people who'll testify before the review committee are the ones who'll tell them everything's rosy. The committee doesn't want to hear the truth.

‘I'll tell you exactly how it will go. They'll bring in an MP who is ostensibly independent. They'll assemble a few retired healthcare professionals desperate to make their name so that they can get their next title, their gong for community service, their government nod. Then they'll interview a few people here and there carefully selected by administration. You think the hospital's general manager is a fool? He's a self-preservationist of the highest order. In a couple of weeks, they'll release the report. The minister will get on TV and say, “I will implement the majority of the recommendations.” Everyone is happy. End of subject. Next week, the news is about something else, and few can remember the disaster until the next time it rears its ugly head.'

Derek finally stopped to draw breath, and the scrub nurse
piped up. ‘I hear surgeons complaining and carrying on, but every time we have a meeting of the theatre committee, no surgeons turn up. You're always too busy in your private rooms making money. You don't give a shit about the decisions that are made each day here in the theatres. I remember when you used to turn up and chair that committee, doctor. Now you just sit here and whine about the state of the health system. At least us nurses have got on and done something about it.'

‘You nurses only turn up to those meetings to avoid work,' Derek blustered. ‘I'll come to meetings that are held after hours, because if a nurse is willing to give up her spare time then it must be worthwhile.

‘I'll tell you what the function of administration
should
be in this hospital. Their real job should be nothing more than to make sure that when I come in to operate, I have the correct stitches I need and the light bulb is changed.' Derek was clearly enjoying himself.

‘Come on, Derek. You can't believe that. You need people to administer the budgets, the resources. Running a hospital must be a very complex thing,' Vincent said, defending the nurse.

‘It
is
complex. The problem is that the people running it have no idea what it's like to be at the coalface. Let me ask you one thing: what's the purpose of the health system?' Derek seemed to be asking the whole theatre all at once.

‘I suppose it's to make sick people better,' answered the scrub nurse.

‘Correct. That's what it's supposed to do – make sick people better. Now, if you designed a health system to do that, would it look like the top-heavy mess we now have? The answer is no. The purpose that this health system serves is ensuring that the minister is protected. Do you know what proportion of the health
budget is chewed up in preventing the minister from being on the front page of the paper? What proportion of the budget is administration and bureaucracy?' Derek stopped briefly, as if waiting for their answer. ‘No. You wouldn't know. Nobody knows. You know why nobody knows? It's impossible to get the figures. You look at the annual report of this hospital or the annual report of the health department. You'll find line items for doctors, nurses, pharmacy, radiology, pathology … but no line item for management, bureaucracy, administration. The best estimate I've heard is that it takes up about 40 per cent of the health budget. More than half this hospital's buildings are administrative blocks. There are as many administrators working in this place as there are nurses.'

‘How long have you got to go with this operation?' cut in Vincent, who wanted to plan the rest of the evening's surgery. ‘Shall I give the next guy some midazolam?'

‘We're almost there. Go ahead and give it to him.'

Vincent disappeared into the anteroom to give Jonathan a little sedative. We all suspected he was listening to the whole conversation. His sedative, though, would mean he'd remember very little of what he had heard.

Having finished the operation, Derek removed the equipment from the patient. A few minutes later, Jonathan was brought in. I scrubbed as he was put to sleep. When I returned, he was asleep with his legs up in the air in stirrups, ready for me to cystoscope him. Derek stayed around, as much for the company as out of curiosity. I inserted the large resecting cystoscope through the eye of Jonathan's penis and slowly advanced into his bladder. Emanating from the left side of his bladder wall was a large fungating tumour – it had the appearance of a clump of red bushes. It was advanced and looked aggressive.

‘Shit. This guy's in trouble,' said Derek, looking at the screen.
‘He hasn't responded to the BCG. In fact, it looks like he's progressed. Do some biopsies and a bimanual examination, would you, Mohamed? I'll see you tomorrow.'

I performed the biopsies, removed the scope and examined his pelvis internally. I felt the large, hard and craggy mass that was the cancer in his bladder. It was obviously aggressive.
What a tragedy
, I thought. The man was only young, perhaps a few years older than I was. He was facing a significant crisis, of which he was currently blissfully unaware. He had a lovely wife, and I remembered him telling me about his two daughters when he'd had his first tumour resected. How sad.

By the time I had got to my car, I had forgotten all about Jonathan. Surgeons cannot store the suffering of their patients. They need to have the ability to let go. The Hindus call it
swaha
, a Sanskrit word that implies breathing out the trouble, freeing oneself of the pain. The Thai Buddhists do it physically. They write down their problems and troubles on the outer skin of a hot-air balloon and then launch it upwards. The effect is to physically take away their bad luck. Jonathan's journey was his to travel, and by the time he awoke I would be asleep, dreaming of happier things.