Clinical Judgements

by Claire Rayner

  ‘It does,’ Shirley said darkly. ‘You see if it doesn’t.’ And she had finished the bed rather huffily, not saying another word to Suba, and that had made her miserable.

  And then Sister had called Suba next morning and told her she could go to the theatre with Mrs Walton. Shirley was off duty so there was no one Suba could talk to, and she had stood and stared at Sister blankly when she told her that and didn’t know what to say to her.

  Sister looked at her. Suba quite liked Sister, a cheerful open sort of person, with a broad Welsh accent that sounded friendly and familiar, a bit like some of the family, really, the ones who still had an accent from living in India, so she wasn’t scared when Sister looked at her so directly. She just stood and stared back.

  Sister Morgan sighed a little and leaned back against her desk and folded her arms.

  ‘All right,’ she said. ‘Out with it. You’re a Catholic and you don’t want to look after her, I suppose? Why do I keep on getting you people on this ward?’

  Suba went scarlet. ‘I — well — it’s just — I’m not sure that —’

  ‘Why you girls come into nursing in the first place beats me sometimes,’ Sister said. ‘Why not train in one of your own convent hospitals, for pity’s sake, and then you’d never have any problems? As it is — this is the big real world and you can’t do just what you fancy you’ll do, you know.’

  Suba could feel her face red and hot. ‘I’m sorry, Sister,’ she said miserably. ‘It’s not my fault. It was just that —’ she almost said Shirley’s name and then adroitly changed the words just in time ‘ — that someone told me Mrs Walton’s having an abortion and — well, I don’t know what I ought to do. It’s legal, isn’t it?’ And she stared at Sister wretchedly. ‘It’s not as though it was against the law or something, is it?’

  ‘For heaven’s sake, girl, of course not. And especially for this woman!’ Sister had straightened up and stood there with her hands on her hips staring down at Suba who was very aware suddenly of being only five foot three. ‘Have you read the notes?’

  ‘Oh, no, Sister!’

  ‘Then you should!’ Sister said crisply. ‘And I’d see you did so now if it wasn’t that Miss Buckland’s taken them. Now just you listen to me, young woman. This lady has three children under the age of six. She is a one-parent family — her husband left her when the last one was born. So now she is not only pregnant — and that is her own affair so don’t look so shocked at me — but she has a severe cervical lesion. We thought it was just CIN 3 but now it looks as though it could be invasive. She doesn’t want this baby, and couldn’t cope if she had it. And its father left her too. Just as her husband did. And now she needs surgery to make sure it doesn’t metastasise. You know about the risk of metastases?’

  Suba stared back and said nothing and Sister took a sharp little breath in through her nose and closed her eyes for a moment.

  ‘Spread, Nurse Mahmoudi, spread. She has a lesion in her cervix which is cancerous, it’s gone beyond treating with just a laser or cone biopsy. And though if she wanted the baby we might be willing to risk holding on till she delivers early with a Caesar and then do the hysterectomy, she is adamant she can’t cope and wants treatment now. And so Miss Buckland has agreed to do the operation today. Do you understand?’

  ‘I — I’m not sure, Sister,’ Suba said, still miserably. She thought she did, but it would have helped to have Shirley here to explain it more simply.

  ‘She has cancer, girl! If she has a hysterectomy today there’s no risk to her future health from secondary spread. Her scan is clear. She’ll lose the baby of course, but since she doesn’t want it, that doesn’t really come into the matter, does it? Now, if you want to refuse to take a patient to the theatre because she is to have a hysterectomy, that is a very different matter from objecting on conscience grounds to helping with an abortion, as I see it —’

  ‘I suppose it is,’ Suba said and straightened a little. ‘If she might die if she doesn’t have the hysterectomy —’

  ‘Well, her life isn’t precisely in the balance at the moment,’ Sister said dryly. ‘But the time could well come. In fact it definitely would. Right now, I haven’t time for all this chat. I’ll send someone else to theatre with her — and go and —’

  ‘No, Sister!’ Suba said breathlessly. ‘I’ll take her. I’d like to, really. I mean, it’ll be interesting —’

  ‘So I should think!’ Sister said, and nodded at her approvingly. ‘That’s better! I must say I hoped you’d see sense, and I’m glad I was right. I promise you I won’t try to send you to deal with any other abortions, the social ones, but this one is different, and I’m delighted you’ve the sense to see it. Now, collect the resuscitation tray and help me get her on to the trolley. We’ll give her her premed in ten minutes and then she can go down. You stay with her till she’s in theatre, right? And — let me see.’ She looked at her watch. ‘If you didn’t mind taking a short break you can stay to watch. You’d find it most interesting.’

  Amazingly it was. Suba had been so afraid she would make a fool of herself when she first got to the theatre, being sick or, worse still, passing out, but she didn’t. They had made her take off her cap and tie her hair up in a sort of white helmet and then she had had to put on a gown and mask over her uniform because she was to go into theatre with her patient, but that had been rather fun. She had caught a glimpse of herself reflected in the glass door of an instrument cupboard and she had felt herself blush with pleasure behind the mask. She looked very dramatic and sort of real, like a character from Angels on the telly, and she liked that.

  And Mrs Walton had been so nice, very sleepy and woozy, but awake enough to be worried and to want to hold hard on to Suba’s hand, and she had felt really useful as she stood there beside her while the anaesthetist chattered to her and gave her an injection and then, as Mrs Walton’s grip on her had eased, slid the big tube with the metal end into her mouth and then attached her to the anaesthetic machine. After that the anaesthetist made Suba help him while he set up the drip, putting the needle into a vein in the back of Mrs Walton’s hand, and she had liked the way he had muttered, ‘Good girl,’ at her when she obeyed all his instructions and it all went up as it should, smoothly and easily and without any problems.

  Inside, the theatre had seemed quite mad to Suba for a moment or two, for there were so many people, all shrouded in gowns and masks, and such a powerful mixture of smells and sounds that her head swam. The reek of anaesthetic and disinfectant, the pinging of the anaesthetic machine and the monitors, the clatter of instruments and the loud chatter of the nurses and the surgeons had made it all seem like a scene in a particularly frenetic film; but there had been no time for her to worry, because they made her help them lift Mrs Walton into place on the high narrow table and then there was the bustle of putting towels on her and fussing over her; and Suba stood and watched, wide-eyed over her mask, too enthralled to think about what was happening to Mrs Walton or how she felt herself or anything but the drama and excitement that was all around her.

  Even when they started on the operation, and Miss Buckland, unrecognisable behind her mask, had made a long incision right across Mrs Walton’s belly, just above where the hair had grown before it had been shaved off, she didn’t feel bad. Miss Buckland was talking to the man beside her, who was helping her, saying what she was doing, and listening to her Suba remembered her anatomy lectures. Skin and then subcutaneous fat and then fascia and then muscle and then peritoneum — ‘And we needn’t worry about that,’ Miss Buckland said firmly, ‘because that’s the uterus, well up as you can see — well developed fundus, isn’t it? I’d estimate at least twenty-six weeks, hmm, Edwards?’ And she had chatted on as her knife and scissors moved in the gap that had been made in the green shrouded shape that was Mrs Walton while the retractors held by the man addressed as Edwards held the space clear for her. And still Suba felt all right, and was deeply proud of herself for that fact.

  But then it a
ll seemed to happen rather suddenly. One moment Miss Buckland was head down over the gap in Mrs Walton and the next there was the large rounded piece of tissue on a dish, and the man Edwards was slicing into it and Suba watched him almost transfixed with horror as she realised what it was. That was the uterus, and inside it was the baby. Was he going to do what they had shown her on that film and pull the little thing apart, head first and then arms and legs? Was it dead or alive inside there?

  And she heard a sort of buzzing in her ears and her body felt very cold and the red object into which Edwards was cutting seemed to recede to a long way away. Someone murmured in her ear, ‘Hold on, my girl — let your head droop and flex your legs — come on, tighten your leg muscles —’ as someone else said loudly, ‘I think it might be worth talking to Mr Bulpitt about this, what do you say, Edwards?’

  And then she really did faint, and knew she was doing it and was desperately ashamed of herself and yet grateful at the same time. Blackness was a lot pleasanter than anything else right now.

  Chapter Eight

  Laurence Bulpitt reached Male Medical just in time to see the last piece of furniture being trundled in and he stood in the door and stared down the ward towards the far end where there was a remarkable amount of activity, and frowned.

  ‘Sister!’ he called, but no one responded, though one or two patients looked at him vaguely and then returned to their books and newspapers, or turned over to go to sleep again. And he frowned even more deeply and went marching up the ward, not waiting for the usual courtesy of an escorting member of the nursing staff.

  He found Sister in the last bay, a plastic apron wrapped round her and irritability in every movement she made as, with sharp gestures, she directed the men heaving the furniture around, and Bulpitt stopped at the sight and stared.

  ‘Sister, what in the name of all that’s holy is going on here? Where are the beds?’

  She turned a flustered face towards him. ‘Oh, Mr Bulpitt! Don’t tell me it’s time for your — I’m sorry, it’s just that everything’s in such a tangle here I hardly know — if you’ll just give me a moment, sir. No, Brovery, not there! I gather the wretched man wants it beside the bed, though how the nurses are supposed to get round it, I can’t imagine. Still, that’s not my problem. Right, yes, that’s it. Now make sure the engineers get the phones in, will you? Mr Byford said he’ll have him here at three o’clock, and it has to be all ready then.’ She snorted softly. ‘A press conference! I ask you! Well, Mr Bulpitt — what can I do for you?’ and she came towards him, pulling at the apron and readjusting her cap a little.

  ‘I wanted to talk to you about a patient,’ he said, staring over her shoulder. ‘But that can wait a moment — what’s happening here?’

  ‘It’s no secret, I don’t suppose,’ Sister said crossly. ‘Mr Byford has a very important patient coming in. Edward Saffron —’

  Bulpitt made a little grimace, pulling down the corners of his mouth expressively.

  ‘Has he indeed! He’s a jammy bugger, that one —’

  Sister grinned suddenly and let her shoulders relax. ‘Not for me to say, sir,’ she said. ‘But I can tell you it’s causing mayhem here. I’ve had to rearrange the whole ward, and make all sorts of awkward arrangements so that the wretched man can have a section all to himself. I’ve lost three beds, do you see? That means I’ve had to put an extra one in the side ward, which isn’t equipped for it, and heaven help me if we have a patient needing specialling. I just won’t have the space or the nurses to give special care, will I?’ He has to have a battery of phones here too, it seems — why he can’t use those new mobile things I don’t know, but I gather they don’t pick up calls properly here, what with all our other equipment and so forth — I’ve had some wretched man from the Ministry here for hours fiddling about and driving me potty. Anyway we’re nearly there. At least he’s having private nurses — and I wouldn’t have thought he needed specialling, but I’m grateful all the same. Now, Mr Bulpitt, what can we do for you? I don’t think you’ve any problems with me at the moment, have you?’

  Bulpitt smiled down at her. He liked Sister Sheward. Everyone did, for she was a lively forthright sort of lady and undoubtedly efficient; a rare combination. ‘Not yet, Sister, but I’ve got a beauty for you. If you can spare me one small bed —’

  ‘Mr Bulpitt, are you mad?’ She almost squealed it. ‘Come and look for yourself, please!’ And she turned in a little flurry of nylon uniform and led him down the ward, past the serried rows of beds and their humps of patients towards the far end and her nurses’ station ‘Do you see? Not an empty bed anywhere and all of them set too close together anyway, because I’ve had to fit in the overflow from Mr High and Mighty Saffron’s section. And —’

  ‘There’s an empty one,’ Bulpitt said hopefully and pointed at a corner bed but she shook her head.

  ‘Joe Slater, patient of Neville’s — Dr Carr’s. Bilateral Ca. lungs — he’s down having chemo at the moment on Andrew Green Radiotherapy ward. He’ll be back soon. Doing not too badly actually, though I thought he was terminal when he came in. You can’t have that one, I hope — not for a while anyway.’ And she looked at the bed with its covers neatly rolled, waiting for the return of its occupant, and her face looked bleak for a moment.

  ‘Well, what about the side ward? I won’t need it for that long and it’s very interesting, Sister. You’ll like it —’

  She sighed heavily. ‘Considering I’m supposed to be a medical ward, you know, it’s all wrong I get this sort of pressure. You can’t tell me that this is a purely medical case you’re trying to put on me, Mr Bulpitt.’

  ‘Well, it is and it isn’t.’ They’d reached the nurses station ‘now and she sat down at her desk and he perched on it beside her, his rump pushing her notes to one side. But she didn’t mind, for he was a cheerful pleasant man and she liked him well enough; his patients all adored him and from Sister Shewed’s point of view that was a strong recommendation. The thing is I’ve got the chance to do something rather special and I’m determined to do it — but I can’t do it down on my own Neurology ward because at this time of the year we’re jammed with the summer people.’

  ‘Ah,’ she said and nodded. She’d been a staff nurse on that ward long ago, in her early days at Old East, and knew of its tradition of taking in severely handicapped patients in order to give their relatives a summer break. ‘Still doing it then, are they? I’d have thought they’d have axed that long ago. Not very cost-effective, is it?’

  ‘They don’t seem to have noticed in the office yet,’ Bulpitt said and lifted his brows at her. ‘Heaven help the poor devils when they do. But that’s the problem, you see We’ve got half a ward full of these Alzheimer’s and so forth and I don’t think I can add to their nursing burdens with this case But it’s a nice one, Sister You’ll be fascinated. You’d kick yourself if you missed the opportunity to be involved, truly you would.’

  ‘A little less coaxing, sir, dear, and a few more facts,’ she said tartly and he laughed.

  ‘More matter with less art? Right. Let me explain — but it has to be — well, it’s a matter not to be talked about yet. You’ll soon see why … Have you heard of the work they’ve done in Birmingham on Parkinson’s? It’s a follow-on to some done in America and Mexico, of all places —’

  She squinted up at him. ‘That rings a bell. Cell implants? That piece in the Lancet?’

  ‘Attagirl. Now I know why everyone loves you, Sister. You know what’s going on and say it clearly. Not brain transplants — that drives me potty, as though we were doing Frankenstein stuff — but yes, cell implants. The thing is, Fay Buckland’s got some tissue for me. She’s had to do a hysterectomy on a woman with a twenty-six-week foetus — cervical carcinoma — and she called me because it was still in — well, in good condition when she operated. The tissue’s there and if I use it in the next few hours it would make a considerable impact. I’ve got a patient I’ve been considering. And he’s willing — my God, is
he willing! Almost begging me for it. Well, at least his wife is — and it really seems the time is now. I’ve got the patient, I’ve got the foetal tissue and all I need is the bed. And of course the nursing. Can you help me out?’

  She sat and stared up at him, thinking hard. It was gratifying that so many of the senior men at Old East thought so highly of her; she liked being the one they all came to when they could for special things, but dammit, with bloody Byford’s peerage-in-the-making coming in to the far bay and one of Neville’s terminal lungs, could she justifiably fill yet another bed with a case that didn’t belong in her ward? What would Byford say if she did it again? He’d been nasty enough when he’d discovered she had a patient of Neville’s on the ward; and her face hardened as she thought that. Damn the man! If he could use her ward for his political cases, then she could damn well use it for her own ends too. And being the sort of Sister they all wanted to take their difficult cases to was an agreeable position to be in —

  ‘Where is he now, then?’ she asked with an air of resignation. ‘Because I’ll need an hour or two to get one of these chaps here transferred to your neuro ward. An easy one, who won’t put any pressure on your nurses. A fair exchange, hmm? If they’ll take one of my sad old gents, then I’ll take your Parkinson’s, though he’ll have to stay in Intensive Care for long enough to be safe here without being specialled. I don’t have the nurses for that —’

  ‘I could kiss you, Sister,’ he said jubilantly, and slid off the desk to his feet. ‘I’ll set it all up right now! What time are you off? I want to make sure you’re here when I get this chap to you —’

  ‘I’m on till eight,’ she said and watched him go; it might have been nicer if he actually had kissed her, come to think of it, instead of just saying he felt like it. And she laughed at her own silliness and went back down the ward to harry the maintenance on their way. Her Very Important Patient was due at any moment, and she was determined that her ward would do her proud in every way. You never knew who might turn up when a chap like that was hanging around the place.