The Patient (19 page)

‘I think a single-layer stitch should do it.' He was taking a risk at Jonathan's expense because it was quicker.

Having stitched up the hole in the bowel, Derek removed the prostate and urethra, the tube that Jonathan used to be able to pass urine through. He then lifted up the bladder and kept dissecting it from his abdomen, working his way up towards the top of the organ. He cut across both ureters, the tubes connecting the bladder to the kidneys above, and sent a section of them to be examined in the pathology department to make sure they were clear of cancer. He finished removing the bladder, then set about isolating and cutting out a section of Jonathan's small bowel and converting it into a tube to carry urine from his kidneys.

They were several hours into the operation when the pathology department rang to say the lymph nodes and the ureters were clear of cancer. ‘We sent that stuff ages ago,' Derek said. ‘I'm glad we didn't wait for it. We would have been here till midnight.' Most surgeons waited for the pathologist's report before deciding whether or not to
continue the operation. If cancer had spread to the ureters and lymph nodes, it was likely to have spread throughout the patient's body. In those circumstances, removing his or her bladder would usually be pointless and inadvisable.

Derek inserted the ureters into one end of the tube he had formed from a piece of small bowel and fixed it so that the other end opened at the surface of the skin on the belly. Jonathan's urine would flow into this newly formed tube instead of flowing towards his now-removed bladder. A stoma ring was then attached to his skin at the external opening of the tube with biocompatible glue so that a bag could be attached to it to collect urine. Finally, Gemma closed the abdomen; Derek usually let her do this part while he wrote up the notes. The wound was dressed, and Jonathan was transferred to the Intensive Care unit for monitoring overnight. He had a tube in his windpipe to help him breathe. He had a tube from his nose to his stomach draining away his digestive juices because for the first few days after surgery his intestines were paralysed and would not drain the juices away. The juices were pushed up each time he coughed or moved. Despite its discomfort, the tube was far better than vomiting post-operatively. He also had an arterial line, a central venous line and several drains in his abdomen.

The next morning, Jonathan opened his eyes and started to make gurgling sounds. The tube down his throat was irritating him.

‘You are fine,' said a nurse in a comforting tone. ‘You're in the Intensive Care unit. I'll take out your tube now, and
you'll feel a lot better. Don't try to talk. You won't be able to.' She was speaking in a loud voice with her face directly over Jonathan's. ‘You have a button under your left thumb. You can press it if you have pain. It will automatically give you intravenous medication to help control the pain. Make sure you use it as often as you need it. You cannot overdose yourself. It is designed to prevent that. OK?' She was working on the tube as she spoke.

Tracy was allowed to visit that morning but couldn't stay longer than a few minutes as she started sobbing uncontrollably to see her husband in this state. During the surgery, his legs and pelvis had been elevated, and, because the surgery had taken so long, his face was now swollen. She almost couldn't recognise him. Later, Derek came in to make sure his handiwork had survived the night.

Images drifted into and out of Jonathan's mind as he lay in that Intensive Care bed. Tracy and his daughters, his father, Carter, Jake, all swirled around like leaves in the wind. At some point, his father came in and said a quiet prayer beside his bed. The girls visited briefly. Slowly, reality replaced fantasy, and he was able to focus on the present.

By the beginning of the second day, he was much more in focus and for the first time started feeling pain. There was a sharp pain that overwhelmed him whenever he moved, and then there was a deep and dull pain. It was constant and invaded every waking moment. By the end of the third day, he was unable to sleep because of it. His medication was increased. There was talk of him being unusually susceptible to pain, a weakling. Eventually, the nurses became curt with his constant grunting and complaints. Patients
who complained too much did not endear themselves to hospital staff.

‘Can you pinpoint where you are feeling the pain exactly?' Derek asked on the evening of the third day.

‘There's the sharp pain where the wound is. That seems to be getting much better now. But there's another pain. It's deep down somewhere.' Jonathan couldn't explain it any better than that.

‘If it continues another night, we'll send you down for a CT scan,' Derek said, his tone reassuring.

When Tracy came in to visit that afternoon, the receptionist at the hospital's front desk stopped her and asked if she had a minute. ‘The accounts manager needs a quick word, Mrs Brewster. She's in her office expecting you.' The receptionist guided her around behind the reception desk.

‘I'm so sorry to bother you at a time like this,' said the accounts manager. ‘I know you must be very worried about your husband. However, the original quotation we gave you only included one night in Intensive Care. Mr Brewster has needed to be there for three nights so far, and it looks like he will need an extra night. That has added a considerable amount to the bill, and I just need to know whether you will be making another deposit to cover this extra amount.' She was polite but to the point.

‘How much are we talking about?' Tracy had a faint edge of panic in her voice.

‘Well, all up it's about double what we quoted.' The accounts manager had had this conversation with several people each week since she'd started working at the private hospital five years ago. It was the low point of her job.

‘I see. I'll talk with his doctor and my father-in-law.
We'll sort it out somehow.' Tracy left without thanking the woman.
This is a business
, she thought,
a straight-out business
.
There is no humanity or compassion here.
She was right, of course. Private hospitals are designed to make a profit for the shareholders. They provide good care, and some even provide wine with dinner. However, they are not charities. Some of the most exclusive and costly private hospitals are run by the Catholic Church, as if to dispel any notion of a separation between church and stately matters.

She pushed the call button at the door of the Intensive Care unit. ‘Mrs Brewster to see my husband,' she called into the intercom.

‘Just a minute, please. We'll be with you shortly,' the ward clerk answered.

‘That's odd,' muttered Tracy under her breath. Normally they just let her in immediately.

The reason they didn't was that just five minutes previously Jonathan's wound had started seeping fluid. At first, the nurse thought it was a small haematoma – a build-up of internal bleeding – beneath the skin, but she soon realised it was much more than that. The fluid was bloodstained initially and then turned greenish. It was the contents of Jonathan's bowels. His wound had formed a fistula – an opening – from his bowel out to the surface of the skin. He was essentially leaking shit onto the front of his belly. Left untreated, he would be dead within a couple of days.

Derek had been called, and he in turn had called Gabe and Gemma and lined up the theatre for urgent surgery. Tracy saw Derek rush into the Intensive Care unit and felt a jolt of fright. She sensed that something dreadful was happening to her husband. Unwilling to wait any longer,
she pushed through the doors and into Jonathan's cubicle. Immediately, she was struck by an overwhelming smell of faeces and urine. The dressings on the front of his abdomen were soaked with a greenish fluid, and Jonathan looked very frightened. Her first reaction was to vomit, which she did onto the floor next to his bed.

‘What's happening? What's going on?' asked Tracy, looking at the nurse and then at Derek.

They stood silently for a moment, then Derek took her by the elbow and said, ‘Let me talk to you outside.'

‘Don't leave. Please talk to me. What is going on? I want to know too,' demanded Jonathan.

Derek turned and guided Tracy back to Jonathan's bedside. ‘It looks like we have had a small setback. When we did your surgery, the bowel had to be opened to make the tube that's now draining your urine away. It looks like there is a small leak from where the bowel was cut and sewn back together. This sometimes happens and is of no major concern. It looks worse than it is,' he said, trying to look unflustered. ‘What it does mean is that we need to take you back to the operating theatre and open you up again to fix it. It is a small setback.'

‘But this is going to cost more money.' Jonathan was the first to speak. ‘Could this be done in the public hospital? I can't afford to stay here any longer.'

‘Look, this is an emergency. We need to operate on you tonight,' replied Derek.

‘I want to be transferred to the public hospital. I refuse to have any more treatment here.' Jonathan's tone was adamant.

‘If we take you to the public hospital, it might be a
couple of days before we can get your operation done,' said Derek. He should also have told them that if Jonathan had the surgery done in the private hospital, he would get paid about six times more than if the operation was done in the public.

Tracy and Jonathan looked at each other, not knowing what to do. Tracy said, ‘We'll work it out later, darling. The only important thing now is to make sure you get your operation done.'

‘That's the attitude. Look, I'll see if I can talk to the accounts department here and get your bill reviewed. After all, making you better is our first priority.' Derek gave a reassuring smile, but to Jonathan it looked like a sinister smirk. Jonathan was too weak, too sick to think this through. He had to rely on Tracy. Had he been compos mentis, he would have thought about the conflict of interest that Derek Johnson had in advising Jonathan about where to have his operation.

An hour later, Derek, Gemma and Gabe were reassembled in the theatre for the unpicking of the wound, the saline washouts of the abdomen and the attempt to find the leak. Assistant and anaesthetist were not happy to be there. This was the third patient they'd had to take back to theatres that month with Derek.

‘Did you tell the patient about the hole you made in the bowel during the cystectomy?' Gemma asked. The theatre went absolutely dead. Everyone was stopped in their tracks, including Derek. Gabe and the nurses looked at her disbelievingly. Perhaps it was her tiredness that had made her speak out. Perhaps she had not really meant for the question to come out sounding so accusatory. Or perhaps
she simply could no longer contain her unease over the surgeon's dishonesty and ineptitude. Derek had her fixed in his steely stare.

‘Well, did you?' Gemma repeated.

He was inwardly stung by her accusation that he had not told the patient that his incompetence had caused the complication. She was right – he had indeed not disclosed his
little accident
with the bowel to Jonathan – but he was not going to let an assistant surgeon get the better of him. He pulled himself up to his full height and said, ‘What are you saying, doctor?' His voice was menacingly slow and deliberate.

Gemma quailed at his tone and immediately thought of all the ways he could make her life very difficult. She needed him more than he needed her. Assistants were a dime a dozen, and her income was derived primarily by assisting him. She glanced across at Gabe, hoping for support, but he was fiddling with the various settings on his monitoring machine to avoid partaking in the embarrassing confrontation that was now playing out.

‘I simply meant that it must have been hard to tell him that the bowel had leaked,' she said in a conciliatory voice. She was sweating profusely with the tension; she had been on the precipice of challenging a surgeon with a mighty reputation for defeating his challengers. ‘Of course, it's probably best not to worry him further given that he's in such dire straits as it is.'

‘I see what you mean. He's running out of money too. I'll probably have to transfer him to the public tomorrow to recuperate after this.' Derek was allowing her to exit with her pride intact.

After several hours, Jonathan was taken back to the Intensive Care unit. Derek went and found Tracy in the waiting room.

‘Look, he is fine now,' he told her. ‘We had to remove a little bit more of his bowel. In the previous operation, we had to make a small hole in his bowel to ensure that we could get his bladder out, and he had a leak from that hole. I think it's probably due to the stress he's under. I've asked the staff to take extra-special care and to let me know if there's any change in his condition. I suggest you go home and try to get some sleep.' With that, he turned his back and was on his way home.

Tracy did not heed his advice but rather rang the button to gain admission to the ward so that she could see her husband. She stood silently, in shock, at the end of his bed while a nurse wrote down his vital signs. It was difficult for Tracy to understand how it was possible to insert so many tubes into one man. Some were draining blood, and some were draining a greenish fluid, obviously the remnants of what had leaked out from his bowel rupture. Another tube was draining urine. It was so frightening to see the man she loved in this state. A ventilator was inflating his lungs, helping him to breathe.