The Patient (8 page)

‘It's pretty big.' Damian hadn't seen too many tumours in his life; this was a big operation for him as it was only his first year in Urology. He was hoping to get onto the training program next year.

‘You'll be right,' said Derek on his way out the door.

Damian removed the cystoscope, unscrewed the camera and screwed on a different kind of instrument, a resection scope, which would allow him not only to see inside the bladder but also to operate on it.

Near his foot were two pedals that controlled the resection scope. If the surgeon wanted to cauterise tissue – burn
it – he pressed the left pedal with his foot. If he wanted to cut it off, he pressed the right one. What Damian didn't know was that when the nurse who had set up for the procedure had connected the scope to the diathermy machine, which produced the electric charge necessary for cauterising, she had accidentally reversed the pedals.

Part of the tumour was in Damian's sights on the screen. It was so big that he couldn't see the whole of it at any one time. He went to begin cutting, by pressing down on the pedal on the right. There was a lot of smoke and boiling in the bladder, but not much happened to the tumour.

‘It looks like the left and right pedals have been reversed,' he said, to no one in particular. He adjusted his stance and started again, this time pressing his left foot down. It felt odd to be using the wrong foot, but it worked properly this time. Slowly, he moved around Jonathan's tumour, carving small portions of it away. Every now and then, he would stop to empty the bladder of all the bits of tissue that had accumulated. These would be collected and sent to the pathologist for analysis to see what type of tumour they were dealing with.

Damian, who was in his second year of surgical training, having completed his necessary year of internship, spent a lot more time picking out his next female companion than studying his books. For that reason, his theoretical knowledge was deficient – but he was great with his hands and was going to be a great surgeon one day, in keeping with the aphorism repeated throughout the medical profession: a physician is someone who knows everything but does nothing; a surgeon is someone who knows nothing and does everything; a pathologist knows everything and does everything, but always too late.

Damian had reached the base of the tumour. Reminding himself that today the left pedal was for cutting, he took one more slice – and suddenly cut across a large, pulsing arterial bleeder. He immediately had a ‘red out'. Fighter-jet pilots use the term when G forces drop so low – when the plane makes a sudden dip, for instance – that blood infuses their brains and they start to have blurred red vision, just before they fall unconscious. Urologists call it a ‘red out' when bleeding in the field of operation overwhelms the water or other clear fluid being used to irrigate the bladder, so you see nothing as you operate, apart from bright-red blood. It's very frightening unless you have well-defined procedures to find the bleeding point and cauterise it. The heat immediately seals the flesh and stems the blood flow.

‘Please call in the surgeon,' Damian said in a tense voice. The unscrubbed nurse ran to the tearoom in search of Derek Johnson.

Damian started to see if he could identify the source of the bleeding. He emptied Jonathan's bladder, and almost pure blood drained out. He then asked the anaesthetist to raise the pressure on the irrigation, and then slowly and steadily looked around the edges of the wound he had created while removing the tumour. With the increased irrigation pressure, he could just make out the lining of the bladder, and after several bladder-emptying manoeuvres he found the bleeding point. He steadied the resection scope, preparing to cauterise it, just as Derek came into the room.

‘I have found the bleeder,' Damian told him.

‘Well, what are you waiting for? Buzz it!' barked Derek. He wasn't happy about having his conversation with the
newly appointed professor of surgery cut short in the tearoom.

Damian steadied the cystoscope again and quickly pressed the left pedal to cauterise the bleeder. Simultaneously, two things happened. He realised that he had pressed the cutting pedal instead of the cautery pedal, having reacted instinctively. The second was that, once again, there was a red out. This time it was almost purple.

‘Oh, fuck!' shouted Derek, and he went to get scrubbed to take over from the young registrar.

Damian was struggling. He looked up at the anaesthetist Elizabeth, who was checking some blood that she had asked for from the blood bank as soon as he'd hit the arterial bleeder. She was a great anaesthetist.

‘Don't worry. It can happen to anyone. He'll fix it,' she said in a calming voice.

Derek came back in, his gown half-hanging off him. The nurse was trying to do up the back of it as he sat down and took over the resection scope from Damian. He found the bleeder and pressed the left pedal down. The cutting came on again.

‘Who the fuck reversed the polarity on the foot pedal? Reconnect them, please. I need them in standard configuration.' He knew he could adapt, but he also knew that in the heat of the moment, when the blood and shit hit the fan, things needed to be the way they were designed to be. Not reversed. Not different. Just the way they were designed to be. He hated any changes when operating, be they to his operating team, the instrument layout or any other part of his theatre, let alone left and right pedals being swapped. Meticulous attention to detail was how patients had good
outcomes, but young doctors and nurses didn't seem to understand its importance. What he didn't seem to realise is that he should have remained in the theatre in the first place, leading by example, rather than working on his political agendas in the tearoom.

Derek found the bleeding point and cauterised it; the bleeding stopped almost immediately. The irrigation won against the blood, and the image on the screen was clear again. He quickly finished the resection, took the biopsies he needed from the other side of the bladder and prostate, and took out the scope. Minutes later, a catheter was inserted into Jonathan's bladder and he was transferred to the recovery suite by the anaesthetist, none the wiser to the dramas that had threatened to take his life.

‘I can't breathe … I can't breathe!' Jonathan was shouting at the top of his voice in the recovery unit.

‘I have a doozy here,' the nurse attending him said to the nurse in the next cubicle. ‘It's OK. Just try and relax, and breathe normally,' she told him in soothing reassuring tones.

‘Please let me sit up. I need to urinate. Help me, please.' Jonathan was in a blind panic. The pain in his groin was unbearable. He felt as though he was wetting himself.

‘Can you come with me to check some drugs, Susan?' she asked her neighbour. Nurses had to visit the drug cupboard in pairs, so there was always a witness to the exact drug and dosage taken, to avoid abuse by staff. It was not uncommon for narcotics to go missing. Seconds later, she was back with a sedative and a narcotic to subdue Jonathan's pain, his anxiety and his complaints.

‘I really need to urinate. Please. I'm going to wet myself.' He was still shouting but more slurred than before.

‘You have a tube in your bladder collecting your urine. It just feels like you need to urinate. Just calm down,' the nurse said, with a slightly sterner edge to her voice.

Jonathan got up on one elbow, threw off his sheets and looked down to see a plastic tube emanating from his penis. The tube seemed to contain two different passages, as bright-red fluid was draining from it while a clear fluid was passing into it from a bag hanging on a stand nearby. He felt faint and fell back onto the bed. The sedation was beginning to work, as was the narcotic.

A couple of hours later, he awoke in a ward. Tracy was sitting in the chair next to his bed, sleeping. He grunted, and she immediately woke and sat forward, a concerned look on her face.

‘How are you feeling, darling?' she said. ‘Any pain?'

‘Not really … only if I move, and then the tube seems to dig into my bladder. What did the doctor say?'

‘He hasn't been around yet. The nurse said he comes in only after he's finished in theatres.' Tracy had checked several times, but no one knew anything more about Derek Johnson's movements.

Jonathan looked around the room in a dazed state. There were three other beds. Opposite him was an old man who was making a gurgling noise. He breathed through a tube inserted through a hole in the front of his neck, and it seemed from the spluttering noise he was making that there was a plug of mucus blocking it. Every now and then, he would try to force the mucus out of his breathing tube through the hole in his neck, to no avail. The curtains of his cubicle, his pyjamas and his sheets were covered with little spots that looked like moths from a distance, but the reality dawned on Jonathan that they were previous mucus plugs.

Next to him was a young teenage boy with a broken arm. Tracy whispered to him that she'd heard he had been
waiting for three days for a plate to be inserted into his arm by an orthopaedic surgeon, but other cases had kept coming in that were more urgent. A white substance was scattered over his bedsheets, which at first Jonathan couldn't make out – it turned out to be plaster from several days previously when they'd put on a temporary cast to stabilise his fracture. Nobody had changed his sheets since then, and, to top it off, he was still in the school uniform he was wearing when he was brought into the hospital.

The curtains were drawn around the cubicle on the other side of Jonathan's, but through a gap he could make out that it was occupied by an older man. A beautifully dressed woman of about 60, no doubt his wife, was giving him a bath. This menial task seemed at odds with her impeccable clothing – it looked as though she might be wearing a Chanel suit. From the care with which she bathed him, it was obvious she was very much in love with her husband and devoted to him. She turned her head and caught Jonathan's eye. Her eyes were sunken and looked as though they had shed an ocean of tears, but Jonathan could also see in them immeasurable inner strength. He smiled. The woman held his gaze for a moment then turned away.

Today was one of the rare days that Derek decided to do the rounds instead of leaving it to the juniors, and he started off with Jonathan. Normally, if he did ward rounds he liked a large entourage, which could include medical students, nurses, interns, residents and registrars. Today, he had an audience of only Damian.

‘All went well today in theatres. The cystoscopy confirmed the tumour. We cut that away and have taken biopsies from different parts of your bladder. We won't
know much till we see the results of the pathology. Should be through in about three days. How are you feeling? OK? No questions? Right, see you later then.'

Derek was well practised at the post-operative spiel. The sooner he finished with Jonathan, the sooner he could get through the ward round and get to the next hospital. He needed to see his patients at three private hospitals before he could get home. It was more important that he see the private patients himself, as they didn't have the luxury of a registrar and a resident to look after them when he wasn't there. In addition, they paid money for him to conduct their surgery.

Tracy spoke up: ‘Do you mind if we ask some questions?'

Derek turned around, visibly disappointed that there was going to be a delay. ‘Yes, sure. What would you like to know?'

‘Well, you said you took biopsies. Biopsies usually mean some sort of cancer. What has Jonathan got? Do you mean that this thing in his bladder is a cancer? We'd hoped it could be stones.' She was teary.

‘Well, I did say that we would not know anything until the pathology comes through. But Jonathan does not have stones. He has a tumour of the bladder. Probably caused by him smoking. We don't know if it has invaded into the bladder or has spread anywhere yet. We need to wait for the pathology. OK?' The subtext was:
Please do not slow me down now; I really have a lot to do.

Jonathan was quite numb. He had heard so many words that confused him and that he thought could never be associated with him: cancer, tumour, spread, invade. Were they
dealing with an alien invasion of his body? Images came to his mind of Sigourney Weaver having some gross creature bursting out of her chest. Tracy was dumbstruck. Derek was pleased with himself. He had been able to demonstrate the elements of good communication to his junior colleague. After all, teaching was part of his job at the hospital. He turned away and stood waiting for him to follow.

At the exit from the ward, he shouted, ‘Where is the charge nurse? Virginia is never here when I come in. What type of meeting is she at now?' He was talking about the nurse in charge of the ward. These nurses used to be called charge sisters, but now they were ‘nursing unit managers'.

In fact, Virginia was at her fourth meeting for the day, a gathering of the Hospital Equipment Committee. A senior anaesthetist had requested bigger garbage bins in one part of the hospital, and this agenda item had taken up most of the time allotted for the meeting. In preparation for the discussion on the hospital's policy regarding garbage-bin sizes, a long paper had been written on the topic.

Most of the members of the committee, especially the hospital's general manager, opposed the anaesthetist's desire for a larger garbage bin. ‘We have always used the 45-centimetre bin,' he said. ‘This issue has been rejected by the Waste and Recycling Committee on the basis that 60-centimetre bins may contribute to additional waste generation in the hospital. I see their point: if there are bigger bins, then it is likely that doctors and nurses will put more garbage into them on a per capita basis.

‘It was also considered last week at the Interdepartmental Quality Control Committee and the Intradepartmental Quality and Audit Junior Management Committee. Both
committees have voted against bigger garbage bins. The stated reasons were simple: smaller garbage bins mean fewer back injuries from wardsmen lifting them. Although the difference in weight is only about one point eight kilograms – I asked the biomedical department to analyse this difference – the possibilities are that, over time, we may see more injuries from the repetitive picking up of these bins. So, on balance, I think we should reject the suggestion for bigger bins.'

The general manager had finished his monologue, and the majority of the committee went on to vote in his favour. The senior anaesthetist was not going to get his larger bins.

Derek, meanwhile, was still in the ward trying to find a nurse. He knew that his resident would hand over his patients' files to a nurse for him, so it wasn't that he
had
to find one; it was a matter of principle. The nurse looking after Jonathan was on a break. Virginia was at her meeting. There was no one around. He went to the central nurses' desk and saw that the board was lit up with calls from patients needing something. It might have been that they had pain, they were thirsty, they needed help getting to the toilet, they needed their medication now – but the only nurse on the ward was attending to a sick patient and couldn't answer the numerous buzzers calling her to the patients' beds.

‘They reckon we want them to be handmaidens, as if doing a ward round with me makes them handmaidens. I just want them to do their bloody job!' he shouted and with that set off to find a nurse who was either not in a meeting or on a break, to tell her about his patients and what they would need over the next 24 hours. He found her in the
storeroom counting stock for one of a series of audits that had been demanded by management, to account for the large amount of stock that regularly went missing. This week, it was a snap audit to make sure that all the syringes were accounted for.

‘I have just seen the bladder cancer in bed 14D,' he said and glanced down at his notes to find the patient's name. ‘Brewster. I know you're not looking after him, but I want to hand over to someone. He needs more irrigation. His return is quite dark.'

The nurse looked at him blankly. Derek had no confidence that she was going to increase the irrigation to his patient's bladder. His lack of confidence was wise. Of the 30 patients on the ward, four had intravenous infusions that had run out, 12 had not received their medications on time, 28 had not had their sheets changed since admission and all 30 had not had a wash in the last three days.

The whole face of nursing was changing rapidly and for the worse. At a time when most professional groups were trying to inject more industry experience into university degrees, nursing had retreated from hospital-based training in favour of university-based education. This move seemed to be led by nurses in academia with their heads in the sand who were artificially creating a fear that hospital-based training diminished nursing as a profession and produced instead handmaidens for doctors. For the vast majority of doctors, nothing could be further from the truth. Now, instead of being part of a team, nurses came out of university with a resentful attitude towards any who made them feel like they were nurses. It was as if, since university-based nursing education, the graduates in nursing wanted to do
anything but nursing. Hence, the plethora who sought to take on traditional doctoring duties by becoming nurse practitioners, when what the system needed most of all was nurses – nurses proud of nursing and proud to be part of that most honoured of professions.

The chances that this particular surgeon was going to get his patient's irrigation increased were minimal. Who did he think he was, anyway? The nurse went back to counting the syringes for the audit.

Tracy and Jonathan sat in the cubicle in silence. A multitude of thoughts ran through their minds but none they could bear to say out loud to each other. Images of death danced around like ghosts in the dark. For some time, Jonathan had been bleeding heavily through the tube sticking out of his penis.

‘I need the nurse to help me. I think the tube's blocking up. My bladder feels like it's about to burst.' He pressed the buzzer. After several minutes, Tracy went to look for a nurse. One of them had come back from a break and promised to come over shortly.

Jonathan was writhing now. He pressed on his lower abdomen to try to relieve his pain, but it was no use. ‘Oh … pleeeeeassse … someone help,' he groaned. Tracy went again to talk to the nurse.

Finally, she came. Using a syringe full of saline, she washed out the blood clots that had been blocking the catheter. Then she connected a new bag of saline and began running it through the catheter into Jonathan's bladder at a higher rate. He got instant relief.

He sensed that the three other patients in the room had been watching the whole thing.

‘Hard to get them when you need them,' the old man opposite said, holding to his throat a gadget that picked up vibrations and translated them into a robotic-sounding voice.

Jonathan said nothing but silently swore he would not come to the public hospital ever again.

That evening, and overnight, his catheter blocked several times. Each time, it took longer and longer to get help. The next day, he looked a haggard man, with sunken eyes. It was then that his father came for a visit.